EXCISION OF RESIDUAL MASSES OF METASTATIC GERM-CELL TUMORS AFTER CHEMOTHERAPY - THE ROLE OF EXTRAPERITONEAL SURGICAL APPROACHES

Objective To evaluate the efficacy and safety of extraperitoneal surgi cal approaches for the removal of residual masses of metastatic germ c ell tumours in men after chemotherapy. Patients and methods A series o f 75 men (median age 32 years) with metastatic germ cell tumours of te sticular (n=63) or extragonadal (n=12) origin, who had been treated wi th an intensive course of platinum-based chemotherapy, were found to h ave residual tumour masses. Extraperitoneal surgical approaches were u sed on 80 occasions to excise these masses. A thoraco-abdominal extrap eritoneal approach (n=71) was used for large masses and those with int rathoracic metastases while smaller retroperitoneal masses were remove d through 12(th) rib (n=5) or Rutherford-Morrison (n=4) extraperitonea l approaches. Results Complete macroscopic clearance of residual masse s within the thorax and retroperitoneum was achieved in all cases. The median blood loss was 0.8 L and the median in-patient stay was 7 days , Complications included chest infection in four cases, Two patients d ied about 4 weeks after surgery, one from septic pericarditis and anot her after an epileptic fit secondary to brain metastases. Eleven patie nts have developed tumour recurrence, five of whom have died from diss eminated disease. Hence the survival rate and disease-free survival ra te are 91% and 83%, respectively, with a median follow-up of 22 months . Conclusions The thoraco-abdominal extraperitoneal surgical approach for retroperitoneal lymph node dissection after chemotherapy for testi cular cancer is safe and has some advantages over anterior approaches, allowing synchronous removal of intrathoracic disease, improved acces s to nodes above and behind the renal vessels and more rapid post-oper ative recovery.