Resection of postchemotherapy residual masses and limited retroperitoneal lymphadenectomy in patients with metastatic testicular nonseminomatous germ cell tumors.

BACKGROUND: Adjunctive retroperitoneal lymphadenectomy (RPLND) plays an important role in the management of patients with metastatic nonseminomatous germ cell tumors (NSGCT). Currently, a bilateral RPLND is recommended for residual disease after chemotherapy.

METHODS: The authors systematically have removed all residual masses and used intraoperative frozen section analysis to dictate the extent of surgery in the patients with NSGCT: If frozen section revealed necrosis, then a limited RPLND was performed; otherwise, a bilateral RPLND was attempted.

RESULTS: Forty patients with metastatic NSGCT were studied. Of the 40 patients, 21 had necrosis identified in frozen section analysis of the residual mass(es), with 18 (85.7%) confirmed in permanent section. Two patients had microscopic viable germ cell tumor, and one had microscopic teratoma in the residual mass with the remaining RPLND specimen tumor-free. Overall, 18 of 45 patients (45%) had necrosis, 17 (42.5%) had teratoma, and 5 (12.5%) had viable germ cell tumor, identified in permanent section analysis. The median follow-up period was 36 months (range, 24-60 months). Of the 40 patients, 8 (20%) experienced recurrences, although none were in the retroperitoneum; 5 were chest recurrences (4 germ cell, 1 teratoma), 2 were retrocrural recurrences (teratomas), and 1 recurrence was with liver metastasis. Of the tumors of the 21 patients with frozen section analysis showing necrosis who underwent resection of residual mass(es) and limited RPLND, 3 (14.3%) experienced recurrences; 2 had germ cell tumors in the chest, and 1 had liver metastasis. The remaining 18 (85.7%) patients had no evidence of disease, with a mean follow-up of 33 months (range, 24-60 months).

CONCLUSIONS: These results suggest that in patients with metastatic NSGCT of the testis, postchemotherapy resection of all retroperitoneal masses followed by limited RPLND if frozen section analysis shows only necrosis is a safe alternative to a difficult, potentially morbid bilateral dissection.