Matveev V B, Volkova M I, Cherniev V A, Figurin K M, Mitin A V
Urologiia. 2010 May-Jun(3):41-7.
Postchemotherapy retroperitoneal lymph node dissection (RLND) was performed in 70 testicular non-seminoma patients with elevated serum tumor markers (age median 27.0 +/- 8.1 years) from 1983 to 2008. N1, N2, N3, Nx were diagnosed in 4 (5.7%), 10 (14.3%), 35 (50.0%), 21 (30.0%) patients. Distant metastases were present in 23 (32.9%) cases. The level of the initial tumor markers was elevated in all the patients: S1 - 169 (46.0%), S2 - 108 (29.4%), S3 - 51 (13.9%), Sx - 39 (10.6%). According to the IGCCCG prognostic model, 11 (15.7%) patients were classified as good, 19 (27.1%)--as moderate, 16 (22.9%)--as poor prognostic groups. The prognostic group was not identified in 24 (34.3%) cases which started treatment in other hospitals. All the patients received induction cisplatin-based chemotherapy following orchidectomy (first-line--24 (34.3%), second-line--46 (65.7%) which resulted in tumor shrinkage < 50% in 7 (10.0%), 51-90% in 23 (32.9%), > 90%--in 2 (2.9%) cases. The response was not properly assessed in 38 (54.3%) cases. CT scan revealed residual retroperitoneal masses after chemotherapy in all the patients: < 2 cm--5 (7.1%), 2-5 cm--25 (35.7%), > 5 cm--40 (57.1%). The level of the tumor markers remained positive in all the patients. Further chemotherapy was not perspective in all 70 patients who further underwent retroperitoneal lymph node dissection (RLND). Radical RLND was performed in 59 (84.3%) patients. Postoperative chemotherapy was given to 27 (38.6%) cases. Median follow-up was 20.8 (3-137) months. Complications developed in 12.9% (9/70) patients. Mortality was 1.4% (1/70). Histology revealed necrosis in 20 (28.6%), teratoma--in 26 (37.1%), cancer--in 24 (34.3%) specimens. Prognostic factors for cancer in retroperitoneal pathology were the following: S > S1 (p = 0.013), intermediate or poor prognosis group IGCCCG (p = 0.014), absence of embryonal carcinoma (p = 0.003), the presence of choriocarcinoma in the testicular tumor (p = 0.028), second-line chemotherapy (p = 0.001), residual mass > 2 cm (p = 0.006). Five-year overall, specific and progression-free survival of 70 patients was 41.0%, 42.4% and 31.8%, respectively. Univariate analysis revealed an adverse impact on progressive-free survival of category S > S1 (p = 0.015), intermediate or poor prognostic group IGCCCG (p = 0.01), the presence of embryonal carcinoma (p = 0.020) and the absence of choriocarcinoma in the testicular tumor (p = 0.029), tumor shrinkage < 50% (p < 0.0001), incomplete RLND (p = 0.012), an incomplete effect of the combined treatment (p < 0.0001), cancer in the residual mass (p < 0.0001). The multivariate analysis proved predictive value of an incomplete effect of the combined treatment (p < 0.0001). Thus, selected testicular non-seminoma patients with elevated serum tumor markers are curable with surgery. The best candidates for RLND in this group are patients without a tumor markers level increase during chemotherapy, with S1 category, good IGCCCG prognosis, tumor shrinkage > 50% and potentially respectable residual disease.
1983年至2008年，对70例血清肿瘤标志物升高的睾丸非精原细胞瘤患者（年龄中位数27.0±8.1岁）进行了化疗后腹膜后淋巴结清扫术（RLND）。N1、N2、N3、Nx分别在4例（5.7%）、10例（14.3%）、35例（50.0%）、21例（30.0%）患者中被诊断出来。23例（32.9%）出现远处转移。所有患者初始肿瘤标志物水平均升高：S1 - 169例（46.0%），S2 - 108例（29.4%），S3 - 51例（13.9%），Sx - 39例（10.6%）。根据国际生殖细胞癌协作组（IGCCCG）预后模型，11例（15.7%）患者被归类为良好预后组，19例（27.1%）为中等预后组，16例（22.9%）为不良预后组。24例（34.3%）在其他医院开始治疗的患者未确定预后组。所有患者在睾丸切除术后接受了以顺铂为基础的诱导化疗（一线化疗 - 24例（34.3%），二线化疗 - 46例（65.7%）），其中7例（10.0%）肿瘤缩小<50%，23例（32.9%）肿瘤缩小51 - 90%，2例（2.9%）肿瘤缩小>90%。38例（54.3%）患者的反应评估不当。CT扫描显示所有患者化疗后腹膜后有残留肿块：<2 cm - 5例（7.1%），2 - 5 cm - 25例（35.7%），>5 cm - 40例（57.1%）。所有患者肿瘤标志物水平仍为阳性。所有70例接受腹膜后淋巴结清扫术（RLND）的患者进一步化疗均无前景。59例（84.3%）患者进行了根治性RLND。27例（38.6%）患者术后接受了化疗。中位随访时间为20.8（3 - 137）个月。12.9%（9/70）的患者出现并发症。死亡率为1.4%（1/70）。组织学检查显示20例（28.6%）标本有坏死，26例（37.1%）有畸胎瘤，24例（34.3%）有癌。腹膜后病理中癌症的预后因素如下：S>S1（p = 0.013），IGCCCG中等或不良预后组（p = 0.014），无胚胎癌（p = 0.003），睾丸肿瘤中有绒毛膜癌（p = 0.028），二线化疗（p = 0.001），残留肿块>2 cm（p = 0.006）。70例患者的5年总生存率、特异性生存率和无进展生存率分别为41.0%、42.4%和31.8%。单因素分析显示，S>S1类别（p = 0.015）、IGCCCG中等或不良预后组（p = 0.01）、有胚胎癌（p = 0.020）、睾丸肿瘤中无绒毛膜癌（p = 0.029）、肿瘤缩小<50%（p<0.0001）、RLND不完全（p = 0.012）、联合治疗效果不完全（p<0.0001）、残留肿块中有癌（p<0.0001）对无进展生存有不利影响。多因素分析证明联合治疗效果不完全具有预测价值（p<0.0001）。因此，所选血清肿瘤标志物升高的睾丸非精原细胞瘤患者可通过手术治愈。该组中RLND的最佳候选者是化疗期间肿瘤标志物水平未升高、S1类别、IGCCCG预后良好、肿瘤缩小>50%且可能可切除的残留病灶患者。
