Management of the post-chemotherapy residual mass in patients with advanced stage non-seminomatous germ cell tumors (NSGCT)

Since it: is difficult to predict the probability of persistent teratoma or of a viable tumor in patients with normalized tumor markers and a normal C T scan following chemotherapy for advanced stage testis canter, recommendat ions regarding adjunctive surgery have ranged from observation to surgical exploration for all patients. Suggested variables for patients in whom surg ery can be omitted safely, include normal post-chemotherapy CT scans, resid ual abdominal masses of less than 1.5 cm, a 90% or greater decrease in the volume of the retroperitoneal mass with chemotherapy and no teratomatous el ements in the orchiectomy specimen. In contrast, during several investigati ons, the application of the above mentioned criteria resulted in a false-ne gative prediction of approximately 20%, However, recognizing the morbidity of the operative procedure itself in addition to the fact that only 2-4% of patients will develop recurrent tumor confined to the retroperitoneal spac e that: can then be managed surgically or by administration of further chem otherapy, secondary surgery should be avoided if a sufficient follow-up aft er chemotherapy is guaranteed. The extent of adjunctive surgery in patients revealing a residual tumor mass after first-line chemotherapy remains a su bject of ongoing discussions, It has been indicated that: extensive retrope ritoneal surgery after chemotherapy is associated with significant clinical morbidity, A limitation of post-chemotherapy surgery to a resection of the residual mass with or without: an additional modified template dissection appears to result: in an acceptable frequency of retroperitoneal recurrence s and a decreased complication rate. (C) 1999 Wiley-Liss, lnc.