Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_959_Библиотеки_им_академика_М_И_Перельмана
.pdf
194 Challenging Concepts in Urological Surgery
https://t.me/med1917
Figure 19.4 Resected retroperitoneal masses weighing >10 kg.
Expert comment Surgical planning of template dissections
Careful dissection, isolation, and protection of the structures forming the boundaries of the
template resection (bifurcation of the aorta and dissection along common iliac vessel (right or left)
inferiorly, ureter laterally, renal hilum superiorly, inferior mesenteric artery, and either the midpoint
of the aorta or IVC for right and left template respectively) in every case is the safest approach.
When these boundaries are defined and proximal and distal control of the IVC and aorta is
established, then it is feasible to perform this operation with excellent outcomes. The fundamental
surgical principles must not be compromised in those patients considered suitable for robotassisted laparoscopic RPLND. A bilateral template includes both right- and left- sided templates and
is more extensive.
Expert comment Holistic needs of testis cancer patients
All patients, of course, must be treated as individuals and patients with metastatic testis cancer require
particularly careful management. They have typically built rapport with their specialist urologist,
clinical oncologist, and specialist nurses throughout their journey. They are classically young, fit, and
healthy individuals who have unexpectedly had their lives changed irrevocably. Having been through
the trauma of diagnosis, potentially perceived emasculating orchidectomy, fertility concerns, and
effects of chemotherapy, they are faced with the formidable prospect of RPLND. They require careful,
considered, and individualized counselling with regard to their extent of surgery and associated risks.
An MDT approach is essential and the role of additional services can be invaluable (see ‘Clinical tip’
box on young person’s services).
Discussion
The GTS is a rare condition with a prevalence of only 2– 8% in patients with metastatic
NSGCT.18 GTS is defined as an enlarging metastatic mass during or after completion
of appropriate chemotherapy for NSGCT in the presence of reducing or normalized
tumour markers.19 It is most commonly found in the retroperitoneum but can also
be observed in the mediastinum, lung, supraclavicular and inguinal lymph nodes, or
a combination of these.20 Radiological features on CT include evidence of enlarging
masses with presence of calcification, fat, or cystic changes.21 Histology of resected
GTS masses reveals benign mature teratoma with no residual viable malignant germ
https://t.me/med1917
cell tumour.22 GTS masses have the potential for rapid growth and high morbidity and
mortality as they disrupt local anatomy or obstruct other organs and vessels.
Complete surgical resection is essential as the recurrence rates can be as high as 83%
in patients with incomplete resection compared to 4% in patients with complete resection18 and multiple surgeries maybe required to ensure complete resection.23 Resection is
also required to confirm the diagnosis and reduce the risk of malignant transformation.
If the diagnosis of GTS is made during chemotherapy treatment, the proposed induction
course should be completed as planned unless toxicity prevents this or if there is evolving
emergency of a local effect of tumour growth (causing vessel or viscous compression).
Expert comment Role of FDG- PET/ CT in post- chemotherapy residual retroperitoneal lymph
node mass in NSGCT
The role of FDG- PET/ CT in the evaluation of residual retroperitoneal lymph node mass after
chemotherapy for metastatic seminoma has been well documented to diagnose residual viable
tumour. In NSGCT, the role of FDG- PET/ CT is less clear, with studies showing no significant
improvement in accuracy of detecting viable tumour in residual masses over standard CT or serum
tumour markers. Furthermore, it cannot clearly differentiate between teratoma, viable malignancy,
or necrosis. In any case, significant residual or growing retroperitoneal masses should be resected
completely and this further limits the role of FDG- PET/ CT in these patients.
195Case 19 Growing teratoma syndrome in testis cancer
A final word from the expert
All patients diagnosed with testis cancer should go through a stepwise management process
starting with mandatory preoperative estimation of tumour markers and discussions regarding
fertility preservation, contralateral testis biopsy, and prosthesis insertion. A CT scan of the thorax,
abdomen, and pelvis is important for staging the disease.
Following radical orchidectomy, it is important to assess the nadir values of serum AFP, β- hCG,
and LDH to allocate an S category (S1, S2, or S3). Using the combined information from the
site of the primary (testis or retroperitoneal primary or mediastinal), final histology (seminoma
or non- seminomatous germ cell tumour), S category, and staging CT scan to determine
extent/ location of metastatic disease allows patients to be allocated to good, intermediate, or
poor prognostic group as per the International Germ Cell Cancer Collaboration Group.9 No
seminoma patients are classified in the poor prognostic group.
Patients with residual masses after completion of chemotherapy should undergo RPLND at highvolume specialist surgical centres. Benefits of undertaking RPLND at designated specialized sites
are significant and include lower morbidity and mortality, a higher chance of complete excision,
and lower occurrence of infield recurrences. Adjunctive procedures such as nephrectomy,
aortic/ IVC excision and graft replacement, psoas excision, excision of retrocrural masses, bowel
resection, and liver resections should be part of the armamentarium at these specialized sites.
The case presented here of a GTS exemplifies importance of the decision- making process at
the testis SMDT meeting. The prognosis for GTS is excellent if diagnosed in a timely manner
and treated with a radical surgical approach with complete resection of all residual disease.
For complete resection, adjuvant procedures are necessary in 23– 33% of cases including
nephrectomy, bowel resection, and vascular procedures. This aspect has to be taken into
consideration when planning surgical treatment of patients with GTS and patients should be
treated in high- volume specialized centres.
196 Challenging Concepts in Urological Surgery
https://t.me/med1917
Postpubertal type teratoma (not prepubertal) is derived from germ cell neoplasia and is a
malignant tumour with a potential for significant metastasis. This is an interesting phenomenon
as, in many other types of cancer, in situ neoplasia has low malignant/ metastatic potential yet in
germ cell neoplasia this is the reverse.
It must not be overlooked that GTS patients are usually young and otherwise fit and well.
They have had extraordinary upheaval to their everyday working and personal lives, often with
significant physical and psychological side effects from their previous surgery and systemic
therapy. This necessitates a personalized approach to counselling about their often- formidable
procedures and frequently requires significant support from all members of the MDT.
References
1. Laguna MP, Albers P, Algaba F, et al. EAU guidelines on testicular cancer. European
Association of Urology. 2020. https:// uroweb.org/ wp- content/ uploads/ EAU- Guidelines- onTesticular- Cancer- 2020.pdf
2. Kliesch S, Behre HM, Jurgens H, Nieschlag E. Cryopreservation of semen from adolescent
patients with malignancies. Med Pediatr Oncol. 1996;26(1):20– 27.
3. Rives N, Perdrix A, Hennebicq S, et al. The semen quality of 1158 men with testicular
cancer at the time of cryopreservation: results of the French National CECOS Network.
J Androl. 2012;33(6):1394– 1401.
4. Robinson R, Tait CD, Clarke NW, Ramani VA. Is it safe to insert a testicular prosthesis at
the time of radical orchidectomy for testis cancer: an audit of 904 men undergoing radical
orchidectomy. BUJ Int. 2016;117(2):249– 252.
5. Dieckmann KP, Kulejewski M, Pichlmeier U, Loy V. Diagnosis of contralateral testicular
intraepithelial neoplasia (TIN) in patients with testicular germ cell cancer: systematic twosite biopsies are more sensitive than a single random biopsy. Eur Urol. 2007;51(1):175– 183.
6. Williamson SR, Delahunt B, Magi- Galluzzi C, et al. The World Health Organization
2016 classification of testicular germ cell tumours: a review and update from the
International Society of Urological Pathology Testis Consultation Panel. Histopathology.
2017;70(3):335– 346.
7. Moch H, Cubilla AL, Humphrey PA, Reuter VE, Ulbright TM. The 2016 WHO classification
of tumours of the urinary system and male genital organs— part A: renal, penile, and testicular tumours. Eur Urol. 2016;70(1):93– 105.
8. Zhang C, Berney DM, Hirsch MS, Cheng L, Ulbright TM. Evidence supporting the existence
of benign teratomas of the postpubertal testis: a clinical, histopathologic and molecular
genetic analysis of 25 cases. Am J Surg Pathol. 2013;37(6):827– 835.
9. 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(2):594– 603.
10. De Wit R, Stoter G, Sleijfer DT, et al. Four cycles of BEP vs four cycles of VIP in patients
with intermediate- prognosis metastatic testicular non- seminoma: a randomized study of the
EORTC Genitourinary Tract Cancer Cooperative Group. European Organization for Research
and Treatment of Cancer. Br J Cancer. 1998;78(6):828– 832.
11. 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(8):1658– 1686.
12. Hendry WF, Norman AR, Dearnaley DP, et al. Metastatic nonseminomatous germ cell tumours of the testis: results of elective and salvage surgery for patients with residual retroperitoneal masses. Cancer 2002;94(6):1668– 1676.
13. Sheinfeld J. The role of adjunctive postchemotherapy surgery for nonseminomatous germcell tumours: current concepts and controversies. Semin Urol Oncol. 2002;20(4):262– 272.
14. Schirren J, Trainer S, Eberlein M, Lorch A, Beyer J, Bölükbas S. The role of residual tumor
https://t.me/med1917
resection in the management of nonseminomatous germ cell cancer of testicular origin.
Thorac Cardiovasc Surg. 2012;60(6):405– 412.
15. Besse B, Grunenwald D, Fléchon A, et al. Nonseminomatous germ cell tumors: assessing
the need for postchemotherapy contralateral pulmonary resection in patients with ipsilateral
complete necrosis. J Thorac Cardiovasc Surg. 2009;137(2):448– 452.
16. Steyerberg EW, Donohue JP, Gerl A, et al. 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(2):474– 478.
17. Wells H, Hayes MC, O’Brien T, Fowler S. Contemporary retroperitoneal lymph node dissection (RPLND) for testis cancer in the UK— a national study. BJU Int. 2017;119(1):91– 99.
18. Spiess PE, Kassouf W, Brown GA, et al. Surgical management of growing teratoma syndrome: the M. D. Anderson cancer center experience. J Urol. 2007;177(4):1330– 1334.
19. Logothetis CJ, Samuels ML, Trindade A, Johnson DE. The growing teratoma syndrome.
Cancer. 1982;50(3):1629– 1635.
20. Maroto P, Tabernero JM, Villavicencio H, et al. Growing teratoma syndrome: experience of a
single institution. Eur Urol. 1997;32(3):305– 309.
21. Panda A, Kandasamy D, Sh C, Jana M. Growing teratoma syndrome of ovary: avoiding a
misdiagnosis of tumour recurrence. J Clin Diagn Res. 2014;8(1):197– 198.
22. Gorbatiy V, Spiess PE, Pisters LL. The growing teratoma syndrome: current review of the
literature. Indian J Urol. 2009;25(2):186– 189.
23. Priod F, Lorge F, Di Gregorio M, et al. Recurrent masses after testicular cancer: growing
teratoma syndrome. A case report and review of the literature. Case Rep Oncol.
2017;10(3):910– 915.
24. British Association of Urological Surgeons. Retroperitoneal excision of abdominal lymph
node (RPNLD). British Association of Urological Surgeons. July 2021. https:// www.baus.
org.uk/ _ userfiles/ pages/ files/ Patients/ Leaflets/ RPLND.pdf
25. Hinton S, Catalano PJ, Einhorn LH, et al. Cisplatin, etoposide and either bleomycin or
ifosfamide in the treatment of disseminated germ cell tumors: final analysis of an intergroup
trial. Cancer. 2003;97(8):1869– 1875.
26. Tran B, Ruiz- Morales JM, Gonzalez- Billalabeitia E, et al. Large retroperitoneal lymphadenopathy and increased risk of venous thromboembolism in patients receiving first- line
chemotherapy for metastatic germ cell tumors: a study by the global germ cell cancer group
(G3). Cancer Med. 2020;9(1):116– 124.
27. Seidel C, Daugaard G, Tryakin A, et al. The prognostic impact of different tumor marker
levels in nonseminomatous germ cell tumor patients with intermediate prognosis: a
registry of the International Global Germ Cell Tumor Collaborative Group (G3). Urol Oncol.
2019;37(11):809.e19– 809.e25.
28. Aide N, Comoz F, Sevin E. Enlarging residual mass after treatment of a nonseminomatous
germ cell tumor: growing teratoma syndrome or cancer recurrence? J Clin Oncol.
2007;25(28):4494– 4496.
197Case 19 Growing teratoma syndrome in testis cancer
https://t.me/med1917
CASE
20
(a) (b)
https://t.me/med1917
Metastatic testicular cancer:
post-chemotherapy residual mass
and cancer survivorship
Findlay MacAskill
Expert commentary Archie Fernando
Case history
A 34- year- old man was referred to the urology clinic via the ‘2- week wait’ suspected
cancer pathway for assessment of a scrotal lump. He had noticed the lump while in the
shower about a month previously and was concerned that it might be increasing in size.
There was no associated pain, history of trauma, or symptoms suggestive of infection.
He was otherwise well. His past medical history included a previous appendicectomy
aged 14 years and childhood asthma. There was no family history of testicular disease.
On examination, a right testicular mass was easily palpable. There was no associated
hydrocele and no lymphadenopathy. No abnormality was palpable in the left testis.
Ultrasound scanning confirmed a 5.2 × 3.4 × 2.7 cm heterogeneous right testicular mass with increased vascularity consistent with malignancy. The left testis was
normal. Blood tests showed elevated tumour markers: alpha- fetoprotein (AFP) 101.6
ng/ mL, beta human chorionic gonadotropin (β- hCG) 308 IU/ mL, and lactate dehydrogenase (LDH) 275 U/ L. Testosterone level was normal. A computed tomography (CT)
scan of the thorax, abdomen, and pelvis showed a 7 cm retroperitoneal mass in the
inter- aortocaval region likely to be metastatic testicular cancer (TC) (Figure 20.1). No
other abnormality was detected.
Clinical tip Examination
Examination of the scrotum must
always be carried out together
with a general examination to find
possible distant metastases, such as
a supraclavicular node, a palpable
abdominal mass, or gynaecomastia,
which can be present in up to 10%
1
of cases.
Figure 20.1 CT scan of the abdomen and pelvis shows a large inter- aortic mass in (a) axial and
(b) coronal sections.
Learning point Tumour
markers
Serum tumour markers help in
the diagnosis and staging of testis
cancer, and can also be used as
prognostic factors both at the time
of diagnosis and during treatment.
Approximately 10% of TC
is advanced (>stage III) at
presentation and the majority
of these have elevated tumour
markers.2 Increased AFP
concentration suggests a diagnosis
of non- seminomatous germ cell
tumour (NSGCT) or mixed germ
cell tumour (GCT).
1
200 Challenging Concepts in Urological Surgery
https://t.me/med1917
Table 20.1 Adapted prognostic- based staging system for metastatic
non- seminomatous germ cell cancer
Prognosis Type Criteria
Good Non- seminoma (56%):
5- year PFS 89%
5- year survival 92%
Intermediate Non- seminoma (28%):
5- year PFS 75%
5- year survival 80%
Bad Non- seminoma (16%):
5- year PFS 41%
5- year survival 48%
PFS, progression- free survival; ULN, upper limit of normal.
International Germ Cell Collaborative Group (IGCCG).
All:
1. Testis/ retroperitoneal primary
2. No non- pulmonary visceral metastases
3. AFP <1000 ng/ mL
4. hCG <5000 IU/ L
5. LDH <1.5 × ULN
All:
1. Testis/ retroperitoneal primary
2. No non- pulmonary visceral metastases
3. AFP 1000– 10,000 ng/ mL
4. hCG 5000– 50,000 IU/ L
5. LDH 1.5– 10 × ULN
All:
1. Testis/ retroperitoneal primary
2. Non- pulmonary visceral metastases
3. AFP >10,000 ng/ mL
4. hCG >50,000 IU/ L
5. LDH >10 × ULN
4
Learning point Prompt
orchidectomy
In cases of metastatic TC at
presentation, proceed directly
to orchidectomy unless unwell,
multiple lung metastases, AFP
>1000 ng/ mL , hCG >5000 IU/ mL,
or renal obstruction.
Expert comment
Semen analysis
Semen analysis should be included
in initial diagnostics because
up to 50% of men with TC have
impaired spermatogenesis, 29%
have oligospermia, and 11%
azoospermia3; both cancer and its
treatment can have an effect on
spermatogenesis.
Onco- testicular sperm extraction
(onco- TESE) can be offered to
patients who are azoospermic at
presentation.
A multidisciplinary team decision was made to proceed to urgent right inguinal orchidectomy. Semen analysis was performed prior to orchidectomy showing mild oligospermia, with normal semen volume and pH, but sufficient quality sperm for banking.
The patient was in a relationship and neither of them had any children. Following
counselling of the patient and his girlfriend with regard to the likelihood of treatment
impacting future fertility, they opted to cryopreserve semen prior to orchidectomy.
The patient underwent a right inguinal orchidectomy and prosthesis insertion without
complication and made a swift recovery. Tumour markers 1 week following orchidectomy
were AFP 54.2 ng/ mL, β- hCG 1 IU/ mL, LDH 217 U/ L. Histological examination of the
orchidectomy specimen revealed a NSGCT with 40% yolk sac, 40% embryonal, and 20%
choriocarcinoma, stage pT2. Lymphovascular invasion was present and margins clear
of tumour. Histological analysis and tumour markers placed him in the good prognosis
group (Table 20.1). The multidisciplinary team decision was to proceed with three cycles
of bleomycin, etoposide, and cisplatin (BEP) chemotherapy, once he had recovered fully.
Learning point Chemotherapy for NSGCT
Chemotherapy for NSGCT is based on prognostic category:
● Good prognosis: three cycles of BEP. A 5- day regimen is recommended as 3- day regimen was found
to be associated with increased toxicity despite equal efficacy.
● Intermediate prognosis: four cycles of BEP.
● Poor prognosis: four cycles of BEP with consideration of switching to a more dose- intensive regimen
if there is poor marker decline after the first cycle.
A three- cycle BEP regimen should be administered at 21- day intervals with delay only in cases where
patients develop fever with associated granulocytopenia (<1000/ mm3) or thrombocytopenia (<100,000/ IU).
7
201Case 20 Metastatic testicular cancer
https://t.me/med1917
Two weeks after his right orchidectomy and prosthesis insertion, the patient commenced chemotherapy. The dosing regimen used was cisplatin 20 mg/ m2 days 1– 5
with hydration; etoposide 100 mg/ m2 days 1– 5; and bleomycin 30 mg days 1, 8, and
15; with a 21- day interval between the start of cycles. He tolerated chemotherapy relatively well with only mild side effects which included nausea, hair loss, and anaemia.
His tumour markers were checked between cycles. Following the first cycle: AFP
30.6 ng/ mL, β- hCG <1 IU/ mL, and LDH 228 U/ L. Following the third cycle: AFP, β- hCG,
and LDH all normalized.
Expert comment Serum tumour markers during chemotherapy
Serum tumour markers should decline during chemotherapy to indicate therapeutic effect.
Persistence of tumour markers during chemotherapy has adverse prognostic value.
8,9
Switching
Expert comment
Uncertainty about metastatic
disease
In cases where there is uncertainty
about the presence of metastatic
disease (e.g. lymph nodes <2 cm in
size with normal tumour markers),
reimaging after a 6– 8- week period
of surveillance or ultrasound- or
CT- guided biopsy should be
considered prior to treatment.
There is insufficient evidence
to support the use of positron
emission tomography to clarify the
situation in this setting.
to more dose- intensive regimens in poor- risk NSGCT patients with slow marker decline
following the first cycle of BEP may reduce progression- free survival, although not overall
survival.10 Poor- risk patients should be treated within a clinical trial in a high- volume reference
centre where possible.
Current trials
11,12
● Phase III BEP (P3BEP): phase III trial of accelerated versus standard BEP for intermediate- or
poor- risk patients.
● TIGER: phase III trial of salvage chemotherapy comparing conventional- dose chemotherapy using
paclitaxel, ifosfamide, and cisplatin with high- dose chemotherapy using mobilizing paclitaxel
plus ifosfamide followed by high- dose carboplatin and etoposide as first treatment in relapsed or
refractory GCTs.
Six weeks post chemotherapy, a CT scan was carried out to assess treatment re-
sponse (Figure 20.2). This showed a good response with the retroperitoneal mass
reducing in size to 1.6 cm with no other areas of disease involvement.
Learning point First- line
treatment of metastatic GCTs
The first- line treatment of
metastatic GCTs depends on:
● The histology of the
primary tumour
● Prognostic groups as defined
by the International Germ Cell
Cancer Collaborative Group
based on 5202 non- seminoma
and 660 seminoma cases
(Table 20.1)
● Marker decline during the first
cycle of chemotherapy in ‘poor
prognosis’ patients.
4
Figure 20.2 CT scan showing a persistent 1.6 cm inter- aortic mass.
Clinical tip Contraindication
to bleomycin
If bleomycin is contraindicated
(interstitial pneumonitis, lung
fibrosis; chronic lung disease; liver
dysfunction; renal failure) then four
cycles of etoposide and cisplatin
should be used although there is
some evidence that this regimen is
inferior to BEP.
4– 6
202 Challenging Concepts in Urological Surgery
https://t.me/med1917
The patient was extremely disappointed with the news that there was a residual
mass present following chemotherapy. It was explained to him that the management
of this residual mass presents a clinical dilemma as it is difficult to be certain whether
the residual mass contains any viable tumour or is simply ‘dead tissue’ following
successful treatment with chemotherapy. He became tearful during the consultation
and wished to defer further discussion to later in the week. An interim appointment
with the in- hospital counselling support service was arranged and a follow- up review
in 3 days.
Learning point Residual masses post chemotherapy
Post chemotherapy mass in NSGCT is13:
● Fifty per cent fibrosis/ necrosis
● Forty per cent teratoma: resistant to chemotherapy; can grow causing organ compression;
3– 6% transformation to malignant neoplasms such as sarcoma, adenocarcinoma, or primitive
neuroendocrine cancer
● Ten per cent residual GCT.
Future directions MicroRNA- 371a- 3p biomarker
In 2011, a novel serum microRNA biomarker was proposed. Micro- RNAs are small non- coding RNAs
involved in gene expression. Serum levels of micro- RNA- 371a- 3p (M371 test) in patients with stage I,
metastatic, and relapsed TC were compared to classical biomarkers and to male controls. It showed
significantly higher sensitivity and specificity, 90.1% and 94% respectively, with a positive predictive
value of 97.2%.15 micro- RNA- 371a- 3p was also significantly associated with clinical stage, primary
tumour size, and response to treatment. Furthermore, micro- RNA- 371a- 3p showed elevated levels in
relapsed cases, which normalized following successful treatment. This novel biomarker could greatly
improve diagnosis and surveillance in TC, and may help predict the presence of viable tumour in
borderline cases of extra- testicular disease both at diagnosis and after chemotherapy.
15
Expert comment Residual masses post chemotherapy
● Predicting histology of post- chemotherapy masses is challenging. While useful in seminomas >3 cm,
positron emission tomography scanning in NSGCT is only 70% sensitive and 48% specific for GCT.
● Even features such as absence of teratoma in orchidectomy specimen, marker normalization, and
small size of mass (<5 mm) cannot reliably exclude viable tumour.
● In cases where the residual NSGCT mass is >1 cm, surgical resection is recommended.17 However,
some lesions slightly >1 cm may continue to reduce further in size.
● In residual NSGCT masses <1 cm, recommendation is less clear. Although these may contain viable
tumour, >70% contain fibronecrotic tissue only.
● Surveillance is therefore an option in these cases especially with normal tumour markers.
With observation in these cases there is a 9% life- long risk of recurrence with a 70% chance of
subsequent cure.
19
18
16
14
On his next visit 3 days later, following multidisciplinary team discussion, the pa-
tient was offered the options of surveillance with a 6- week interval scan versus surgical resection of the residual mass. The pros and cons of each option were discussed
at length. The patient felt uncomfortable with surveillance but was also anxious about
major surgery. After evaluation of all involved areas present on the initial and posttreatment CT scans he was deemed suitable for minimally invasive robotic- assisted
retroperitoneal lymph node dissection (RPLND) involving a unilateral right- sided
nerve- sparing template. Following discussion of what surgery involved and the as-
https://t.me/med1917
sociated risks, and a further day to confer with his family, he opted to have surgery.
Future directions RPLND
Post RPLND ‘dry ejaculation’ is due to the resection of sympathetic nerves entering the superior
hypogastric plexus and lumbar splanchnic nerves during surgery. The original ‘bilateral template
RPLND’ includes supra- hilar and infra- iliac dissection resulting in dry ejaculation in almost all patients
(Figure 20.3a). Dry ejaculation rates reduced to approximately 75% with ‘modified RPLND’ sparing
the contralateral iliac region below the iliac bifurcation (Figure 20.3b). ‘Unilateral template RPLND’
confined to the ipsilateral side of the aortic midline below the inferior mesenteric artery (Figure 20.3c,
d) was then developed, preserving ejaculation in >80%.20 Donohue et al. subsequently introduced
‘nerve- sparing RPLND’ where the sympathetic nerve fibres were carefully dissected out, identified, and
preserved.21 The 10- year recurrence- free and overall survival of unilateral and nerve- sparing RPLND
in appropriately selected cases, even post chemotherapy, is the same as with bilateral RPLND with
significantly higher rates of preserved ejaculation (>85% compared to <20%).
RPLND in 1992 marked an initiative to reduce surgical morbidity for TC patients. Following the
first robotic- assisted laparoscopic RPLND (R- RPLND) in 2006, experienced high- volume centres
have shown comparable oncological outcomes of R- RPLND with reduced peri- and postoperative
morbidity in the primary setting.
23
20– 22
The first laparoscopic
203Case 20 Metastatic testicular cancer
Figure 20.3 RPLND templates. (a) Standard bilateral; (b) modified bilateral; (c) unilateral modified,
right; (d) unilateral modified, left.
Expert comment RPLND
RPLND in TC is challenging surgery
with up to 30% of patients requiring
additional procedures such as
nephrectomy, muscle resection,
and vascular reconstructive
surgery. RPLND should therefore
be performed in specialist centres.
Centralization of surgery has
reduced mortality from 6% to 0.8%
and local recurrence from 16% to
3%.25 Resection of residual masses
of seminoma is rarely indicated, as
surgery is extremely difficult due to
intense fibrosis.
Соседние файлы в папке Библиотека им академика М.И. Перельмана