Department of Oncology, Central Military Hospital SNP Ruzomberok, Ruzomberok, Slovak Republic.
2nd Department of Oncology, Faculty of Medicine, National Cancer Institute, Comenius University, Klenova 1, 833 10, Bratislava, Slovak Republic.
BMC Surg. 2020 Nov 7;20(1):272. doi: 10.1186/s12893-020-00933-2.
Metastatic germ cell cancer of the testis is characterized by favorable prognosis since effective treatment methods are available even in cases of extensive disease. Retroperitoneal masses frequently encroach major blood vessels requiring a vascular intervention usually performed in association with the post-chemotherapy retroperitoneal lymph node dissection (RPLND). Reported clinical case describes a successful pre-treatment endovascular surgery for abdominal aortic rupture allowing for full-dose systemic chemotherapy administration, and subsequent radical surgical intervention at primary tumor site as well as metastatic retroperitoneal lymph node dissection including the reconstruction of inferior caval vein.
Patient presented with left-sided testicular tumor and voluminous retroperitoneal mass with vascular involvement. Soon after the patient had been admitted for the first cycle of cisplatin-based chemotherapy, computed tomographic angiography (CTA) revealed a dorsal aortic wall rupture with active extravasation and irregular pseudoaneurysmatic dilatation of the aorta below the leak area. Retroperitoneal intratumoral hemorrhage associated with the bilateral iliac venous thrombosis required an endovascular repair procedure of infrarenal abdominal aorta.
Following the successful endovascular aortic repair 3 cycles of BEP (bleomycin, etoposide, cisplatin) regimen were administered with subsequent delayed left radical orchiectomy and RPLND associated with vena cava inferior (VCI) resection. Reconstruction of VCI was originally not deemed necessary as collateral blood flow appeared sufficient, however, intraoperative complications resulted in the need for unilateral VCI reconstruction, using the interposed bypass between right common iliac vein and infrarenal segment of VCI. Histopathologic examination of the attained specimen detected no vital cancer structures. The patient remains disease-free 18 months after the RPLND.
睾丸生殖细胞癌转移的特点是预后良好，因为即使是广泛疾病的病例，也有有效的治疗方法。腹膜后肿块经常侵犯主要血管，需要血管介入治疗，通常与化疗后腹膜后淋巴结清扫术（RPLND）一起进行。报告的临床病例描述了一例成功的腹主动脉破裂的术前血管内手术，使患者能够接受全剂量的全身化疗，并随后在原发肿瘤部位进行根治性手术干预，以及包括下腔静脉重建的转移性腹膜后淋巴结清扫术。
患者表现为左侧睾丸肿瘤和巨大腹膜后肿块，伴有血管受累。在接受顺铂为基础的化疗第一周期入院后不久，计算机断层血管造影（CTA）显示背主动脉壁破裂，有活跃的外渗和漏口下方的主动脉不规则假性动脉瘤扩张。腹膜后肿瘤内出血伴双侧髂静脉血栓形成，需要进行腹主动脉下段的血管内修复。
成功的血管内主动脉修复后，给予了 3 个周期的 BEP（博来霉素、依托泊苷、顺铂）方案，随后进行了延迟的左侧根治性睾丸切除术和 RPLND，同时切除了下腔静脉（VCI）。最初认为不需要重建 VCI，因为侧支血流似乎足够，但术中并发症导致需要进行单侧 VCI 重建，使用右髂总静脉和 VCI 下腔静脉段之间的旁路进行重建。获得的标本的组织病理学检查未发现有活力的癌结构。RPLND 后 18 个月，患者无疾病。
