Buffardi Andrea, Destefanis Paolo, Lillaz Beatrice, Bosio Andrea, Bisconti Alessandro, De Maria Claudia, Carchedi Mariateresa, Rolle Luigi, Fontana Dario
Divisione Universitaria di Urologia 2, AOU San Giovanni Battista Molinette, Torino, Italy.
Urologia. 2011 Jul-Sep;78(3):161-5. doi: 10.5301/RU.2011.8629.
According to the last EAU Guidelines about testicular cancer, surgical resection of residual masses after chemotherapy in NSGCT is indicated in the case of visible residual masses and when serum levels of tumor markers are normal or normalizing. If markers are not normalized and when several chemotherapeutic regimens have failed to cure metastatic disease, resection of residual tumors (so called "desperation surgery") should be offered to these patients.
We are going to present the case of a 30-year-old patient, affected by metastatic NSGCT. According to the prognostic-based staging system for metastatic germ cell cancer, our patient was in the poor prognosis group. The retroperitoneal mass involved all major vascular structures and still caused a bilateral obstruction of the upper urinary tract. Histological examination after radical orchiectomy revealed embryonal carcinoma and immature teratoma. The patient underwent a four-cycle VIP chemotherapy and then salvage chemotherapy with four cycles of TIP. After chemotherapy, the patient still presented large multiple metastatic localizations. Tumor markers were reduced but not normalized. The patient was then proposed for the resection of residual tumor. The residual mass could not be dissected from the left renal pedicle, so the left nephrectomy was unavoidable. The mass was hardly detached from vena cava and aorta. A bilateral iliac and retroperitoneal lymphadenectomy was performed. At the end of the procedure, the retroperitoneal space was completely free.
Post-operative hospital stay was regular. A CT scan performed 3 months after the procedure did not show any residual lesion in the retroperitoneum. Three and six months later, the patient underwent the residual tumor resection of the right mediastinum and then of the left mediastinum and supraclavear metastases. Afterwards the patient underwent an EP consolidation chemotherapy. The patient is alive, 12 months after the retroperitoneal surgery.
Our experience confirms that resection of residual tumors is safe and feasible also in cases of very large abdominal disease.
根据欧洲泌尿外科学会（EAU）关于睾丸癌的最新指南，对于非精原细胞瘤性生殖细胞肿瘤（NSGCT）患者，在化疗后若残留肿块可见且血清肿瘤标志物水平正常或正在恢复正常，则需进行手术切除残留肿块。若肿瘤标志物未恢复正常且多种化疗方案均未能治愈转移性疾病，则应向这些患者提供残留肿瘤切除术（即所谓的“绝望手术”）。
我们将介绍一名30岁转移性NSGCT患者的病例。根据转移性生殖细胞癌的基于预后的分期系统，我们的患者属于预后不良组。腹膜后肿块累及所有主要血管结构，且仍导致上尿路双侧梗阻。根治性睾丸切除术后的组织学检查显示为胚胎癌和未成熟畸胎瘤。患者接受了四个周期的VIP化疗，随后进行了四个周期的TIP挽救化疗。化疗后，患者仍存在大量多发转移灶。肿瘤标志物有所降低但未恢复正常。随后建议患者进行残留肿瘤切除术。残留肿块无法从左肾蒂分离，因此不可避免地进行了左肾切除术。肿块很难从腔静脉和主动脉分离。进行了双侧髂骨和腹膜后淋巴结清扫术。手术结束时，腹膜后间隙完全清除。
术后住院过程正常。术后3个月进行的CT扫描未显示腹膜后有任何残留病变。3个月和6个月后，患者分别进行了右纵隔残留肿瘤切除术，然后是左纵隔和锁骨上转移灶切除术。之后患者接受了EP巩固化疗。腹膜后手术后12个月，患者仍然存活。
我们的经验证实，对于腹部疾病非常严重的病例，切除残留肿瘤也是安全可行的。
