Aprikian A G, Herr H W, Bajorin D F, Bosl G J
Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York 10021.
Cancer. 1994 Aug 15;74(4):1329-34. doi: 10.1002/1097-0142(19940815)74:4<1329::aid-cncr2820740424>3.0.co;2-l.
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.
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.
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).
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.
辅助性腹膜后淋巴结清扫术（RPLND）在转移性非精原细胞瘤性生殖细胞肿瘤（NSGCT）患者的治疗中发挥着重要作用。目前，对于化疗后残留病灶，推荐行双侧RPLND。
作者系统地切除了所有残留肿块，并在NSGCT患者中使用术中冰冻切片分析来确定手术范围：如果冰冻切片显示坏死，则行有限的RPLND；否则，尝试行双侧RPLND。
对40例转移性NSGCT患者进行了研究。在这40例患者中，21例在残留肿块的冰冻切片分析中发现坏死，其中18例（85.7%）在永久切片中得到证实。2例患者残留肿块中有微小的存活生殖细胞瘤，1例有微小畸胎瘤，其余RPLND标本无肿瘤。总体而言，在永久切片分析中，45例患者中有18例（45%）发现坏死，17例（42.5%）发现畸胎瘤，5例（12.5%）发现存活生殖细胞瘤。中位随访期为36个月（范围24 - 60个月）。在40例患者中，8例（20%）出现复发，不过均不在腹膜后；5例为胸部复发（4例生殖细胞瘤，1例畸胎瘤），2例为膈脚后复发（畸胎瘤），1例复发伴有肝转移。在21例冰冻切片分析显示坏死且接受残留肿块切除及有限RPLND的患者中，3例（14.3%）出现复发；2例胸部有生殖细胞瘤，1例有肝转移。其余18例（85.7%）患者无疾病证据，平均随访33个月（范围24 - 60个月）。
这些结果表明，对于睾丸转移性NSGCT患者，化疗后切除所有腹膜后肿块，若冰冻切片分析仅显示坏死则行有限的RPLND，是一种安全的替代方法，可替代困难且可能有并发症的双侧清扫术。
