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  • Title: [Clinical outcome of postchemotherapy retroperitoneal lymph node dissection and predicting retroperitoneal histology in advanced nonseminomatous germ cell tumours of the testis].
    Author: Li XD, Guo SJ, Chen SL, Liu ZF, Dong P, Zhang ZL, Jiang LJ, Yao K, Li YH, Han H, Qin ZK, Liu ZW, Zhou FJ.
    Journal: Zhonghua Wai Ke Za Zhi; 2017 Aug 01; 55(8):603-607. PubMed ID: 28789511.
    Abstract:
    Objective: To explore the clinical outcome of advanced testicular nonseminomatous germ cell cancer patients undergoing post chemotherapy retroperitoneal lymph node dissection (PC-RPLND), and to analyze the relevant prognostic factors of lymph node pathological. Methods: A total of 43 consecutive testicular nonseminomatous germ cell cancer patients underwent PC-RPLND between March 2001 and December 2014 in Department of Urology at Sun Yat-sen University Cancer Center were retrospectively reviewed. The average age of the patients was (29.0±11.5) years (ranging from 12 to 58 years). Before PC-RPLND, 22 patients were classified as phase Ⅱ, while 21 were phase Ⅲ. Primary tumor histology revealed seminomatous elements in 19 cases, embryonal cell carcinoma in 22 cases, yolk sac tumor in 13 cases, chorionic carcinoma in 3 cases, mature teratomatous elements in 11 and immature teratomatous elements in 2 cases. Patients were treated with cisplatin-based chemotherapy after orchectomy and then underwent surgical resection of retroperitoneal lymph nodes.After PC-RPLND, all patients underwent a periodic review including the blood routine, biochemistry routine and computed tomography or ultrasonograph of the chest, the abdomen and the pelvis. The association of pathological data with patient's clinic features and the correlations between molecular features detected with each other were assessed by the t test, χ(2) and Fisher's exact test. Multivariate logistic regression were used to assess prognostic factors. Results: The median operative time was 278 minutes (ranging from 50 to 715 minutes). Median blood loss was 425 ml (ranging from 50 to 5 000 ml). Eight patients received blood transfusion intra-operatively, 2 patients underwent adjunctive surgical procedures, 4 patients developed ileus and 4 had an ascites chylosus following PC-RPLND, 1 patient had a postoperative hyperthermia and retrograde ejaculation was present in 10 patients. The transverse diameter of the residual tumor in patients ranged from 0.8 to 18.2 cm. Necrosis, teratoma and viable germ cell tumors were found in 15, 17 and 11 of all patients. The median follow-up time was 46 months (ranging from 6 to 169 months). There were 39 patients had no tumor recurrence, 7 patients were found recurrence after PC-RPLND, 5 died of malignant germ cell tumor. The normal serum lactate dehydrogenase (LDH) level before chemotherapy (HR=25.811, 95%CI: 0.678 to 982.624, P=0.017) and relative changes more than 50% in retroperitoneal lymph node size (HR=0.016, 95%CI: 0 to 0.698, P=0.032) were statistically significant prognostic factors of the presence of necrosis. Conclusions: Since most residual masses are not sensitive to chemotherapy, PC-RPLND is still an essential part of the treatment of metastatic testicular nonseminomatous germ cell cancer. Patients with the normal serum LDH level before chemotherapy and a shrinkage of 50% or more in retroperitoneal mass have a considerably chance of having necrosis in the retroperitoneum resection. This may help to refine the selection of candidates for PC-RPLND. 目的： 探讨转移性睾丸非精原细胞瘤化疗后腹膜后淋巴结清扫术(PC－RPLND)的疗效及淋巴结病理为坏死的相关预后因素。 方法： 回顾性分析2001年3月至2014年12月于中山大学肿瘤防治中心泌尿外科接受PC－RPLND治疗的43例转移性睾丸非精原细胞瘤患者资料，年龄12～58岁，平均(29.0±11.5)岁。临床分期Ⅱ期22例，Ⅲ期21例。睾丸原发灶病理类型：含精原细胞瘤成分19例，胚胎癌成分22例，卵黄囊瘤成分13例，绒癌成分3例，成熟畸胎瘤成分11例，未成熟畸胎瘤成分2例。所有患者在睾丸肿瘤切除术后均先行化疗，再行腹膜后淋巴结清扫(RPLND)。RPLND术后定期复查血常规、生化常规、胸部、腹部和盆腔CT或超声检查。采用t检验、χ(2)检验和Fisher精确概率法分析患者临床资料与化疗后淋巴结坏死的相关性，并采用logistic回归分析进行多因素分析。 结果： PC－RPLND手术时间50～715 min，平均278 min；出血量50～5 000 ml，平均425 ml，8例需输血，2例手术需其他科协助。PC－RPLND术后并发症情况：肠梗阻4例，乳糜性腹水4例，术后高热1例，逆行射精10例。腹膜后淋巴结直径0.8～18.2 cm，平均3.8 cm。PC－RPLND术后腹膜后淋巴结病理类型：组织坏死15例，畸胎瘤17例；活性癌细胞11例。术后随访6～169个月，中位随访时间46个月，39例患者无肿瘤复发或转移，7例患者肿瘤复发，其中5例死亡。多因素分析结果显示，肿瘤收缩率(HR＝0.016，95%CI：0～0.698，P＝0.032)和化疗前乳酸脱氢酶(LDH)水平(HR＝25.811，95%CI：0.678～982.624，P＝0.017)为化疗后腹膜后淋巴结坏死的预后因素。 结论： 腹膜后淋巴结清扫术是睾丸非精原细胞瘤化疗后残余病灶的有效治疗方式。化疗前血清LDH正常和化疗后肿瘤缩小明显(>50%)的病例，腹膜后残存淋巴结为坏死组织的可能性相对更高，可以作为避免行PC－RPLND的参考因素。.
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