Chapter 38: Urologic Surgery
A 19-year-old man undergoes a left radical orchiectomy for a painless left testicular mass. Pathology reveals embryonal carcinoma (40%), yolk sac tumor (20%), and teratoma (40%). Serum α-fetoprotein (AFP) and β-human chorionic gonadotropin (β-hCG) were both elevated preoperatively. A computed tomography (CT) scan reveals moderate para-aortic lymphadenopathy, and the patient receives three courses of platinum-based chemotherapy. Following chemotherapy, his tumor markers normalize, and a follow-up CT is shown in Fig. 38-1. What is the most appropriate next step?
FIGURE 38-1. Abdominal computed tomography scan showing para-aortic lymphadenopathy.
(B) Repeat tumor markers and CT in 3 months
(C) Administer one additional cycle of platinum-based chemotherapy
(D) Administer two additional cycles of platinum-based chemotherapy
(E) Retroperitoneal lymph node dissection (RPLND)
(E) The CT reveals persistent para-aortic lymphadenopathy following chemotherapy. Ninety-five percent of testicular cancers are germ cell tumors (GCTs), and these are further subdivided into seminomas and nonseminomas. Nonseminomatous tumors are often mixed in terms of their histology and can be comprised of embryonal carcinoma, choriocarcinoma, yolk sac tumor, and teratomas.
Patients with nonseminomatous testicular cancer who are treated with primary chemotherapy and subsequently have negative tumor markers but have a residual retroperitoneal mass ≥1 cm should proceed to bilateral RPLND.
After chemotherapy, approximately 30% of patients will have residual disease on imaging. Of that 30%, approximately 40% will have necrosis in the specimen, 45% will have teratoma, and 15% will have viable malignancy. Therefore, RPLND provides both staging and therapeutic benefits. If viable malignancy is found, then additional chemotherapy is indicated. If teratoma is present, surgical resection is therapeutic because teratoma is not chemotherapy sensitive. It can transform into a malignancy or can cause morbidity secondary to rapid growth and mass effect.
The technique of RPLND has also evolved to decrease morbidity. A full bilateral RPLND is not always necessary, and a modified nerve-sparing RPLND allows for the preservation of retroperitoneal sympathetic fibers and virtually eliminates the risk of anejaculation.
Stephenson A, Gilligan T. Neoplasms of the testis. In: Wein A, Kavoussi L, Novick A, et al. (eds.), Campbell’s Urology, 10th ed. Philadelphia, PA: W.B. Saunders; 2012.
Which of the following is the most important prognostic indicator for patients with renal cell carcinoma?