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Original article

Vol. 153 No. 4 (2023)

Perioperative complications and oncological outcomes of post-chemotherapy retroperitoneal lymph node dissection in patients with germ cell cancer at two high-volume university centres in Switzerland – a retrospective chart review

  • Marco Notarfrancesco
  • Christian D. Fankhauser
  • Anja Lorch
  • Davide Ardizzone
  • Simon Helnwein
  • Dennis Hoch
  • Thomas Hermanns
  • George Thalmann
  • Jörg Beyer
DOI
https://doi.org/10.57187/smw.2023.40053
Cite this as:
Swiss Med Wkly. 2023;153:40053
Published
10.04.2023

Summary

BACKGROUND: Post-chemotherapy retroperitoneal lymph node dissection (PC-RPLND) is an integral part of the management of patients with metastatic non-seminoma and residual masses >1 cm after chemotherapy.

AIMS: To assess perioperative complications and oncological outcomes at two major referral centres in Switzerland.

METHODS: This was a retrospective chart review of 136 patients with non-seminoma who underwent PC-RPLND between 2010 and 2020 at the university hospitals of Bern and Zürich. Patient, treatment and tumour characteristics as well as the types and frequencies of intra- and postoperative complications were registered and compared using the chi-square test. Oncological outcomes consisted of the time and location of relapses as well as progression-free and overall survival, which were compared using the log-rank test.

RESULTS: Overall, 70 patients from Bern and 66 patients from Zürich were included; 5 patients had a previous retroperitoneal lymph node dissection (RPLND) (2 Bern, 3 Zürich). Vascular injuries were the most frequent intraoperative complication, occurring in 27/136 (19.9%) patients. Postoperative complications were observed in 42/136 (30.9%) patients, ileus being the most common. Perioperative mortality was 2.2%. A retroperitoneal mass ≥50 mm was significantly associated with intraoperative complications (p = 0.004) and increased resource demands (p = 0.021). Postoperative morbidity was higher according to age at post-chemotherapy retroperitoneal lymph node dissection ≥40 years (p = 0.028) and retroperitoneal mass ≥20 mm (p = 0.005). The median follow-up time was 37 months (interquartile range [IQR] 18–64 months). The median progression-free survival at 5 years was 76% (95% confidence interval [CI]: 64–85%) in Bern and 69% (95% CI: 54–80%) in Zürich (p = 0.464). The median overall survival at 5 years was 88% (95% CI: 76–94%) in Bern and 77% (95% CI: 60–87%) in Zürich (p = 0.335). Patients with progressive disease or a tumour marker increase before retroperitoneal lymph node dissection had significantly inferior progression-free and overall survival compared to non-progressing patients. The presence of teratoma in resected specimens did not confer inferior survival probabilities compared to necrosis only, whereas the presence of vital undifferentiated tumour conferred inferior progression-free and overall survival. Patients with a previous retroperitoneal lymph node dissection and patients operated for late relapses >2 years after chemotherapy also had significantly inferior progression-free and overall survival.

CONCLUSIONS: We found a relevant rate of severe perioperative complications at PC-RPLND at even experienced high-volume centres. The oncological outcomes at two major university urological centres in Switzerland were similar and determined by preoperative risk factors and intraoperative histology.

References

  1. Siegel RL , Miller KD , Fuchs HE , Jemal A . Cancer Statistics, 2021. CA Cancer J Clin. 2021 Jan;71(1):7–33. https://doi.org/10.3322/caac.21654 DOI: https://doi.org/10.3322/caac.21654
  2. Bundesamt für Statistik / Nationale Krebsregistrierungsstelle. Krebs, Neuerkrankungen und Sterbefälle: Anzahl, Raten, Medianalter und Risiko pro Krebslokalisation. (2020).
  3. de Wit R , Stoter G , Kaye SB , Sleijfer DT , Jones WG , ten Bokkel Huinink WW , et al. Importance of bleomycin in combination chemotherapy for good-prognosis testicular nonseminoma: a randomized study of the European Organization for Research and Treatment of Cancer Genitourinary Tract Cancer Cooperative Group. J Clin Oncol. 1997 May;15(5):1837–43. https://doi.org/10.1200/JCO.1997.15.5.1837 DOI: https://doi.org/10.1200/JCO.1997.15.5.1837
  4. Culine S , Kerbrat P , Kramar A , Théodore C , Chevreau C , Geoffrois L , et al.; Genito-Urinary Group of the French Federation of Cancer Center (GETUG T93BP) . Refining the optimal chemotherapy regimen for good-risk metastatic nonseminomatous germ-cell tumors: a randomized trial of the Genito-Urinary Group of the French Federation of Cancer Centers (GETUG T93BP). Ann Oncol. 2007 May;18(5):917–24. https://doi.org/10.1093/annonc/mdm062 DOI: https://doi.org/10.1093/annonc/mdm062
  5. Krege S , Beyer J , Souchon R , Albers P , Albrecht W , Algaba F , et al. European consensus conference on diagnosis and treatment of germ cell cancer: a report of the second meeting of the European Germ Cell Cancer Consensus Group (EGCCCG): part II. Eur Urol. 2008 Mar;53(3):497–513. https://doi.org/10.1016/j.eururo.2007.12.025 DOI: https://doi.org/10.1016/j.eururo.2008.03.017
  6. Honecker F , Aparicio J , Berney D , Beyer J , Bokemeyer C , Cathomas R , et al. ESMO Consensus Conference on testicular germ cell cancer: diagnosis, treatment and follow-up. Ann Oncol. 2018 Aug;29(8):1658–86. https://doi.org/10.1093/annonc/mdy217 DOI: https://doi.org/10.1093/annonc/mdy217
  7. EAU Guidelines on Testicular Cancer. EAU Guidelines Office, Arnhem, The Netherlands, 2021.
  8. C. T. Nguyen , A. J. Stephenson , Role of postchemotherapy retroperitoneal lymph node dissection in advanced germ cell tumors. Hematol Oncol Clin North Am 25, 593-604, ix (2011). https://doi.org/10.1016/j.hoc.2011.03.002 DOI: https://doi.org/10.1016/j.hoc.2011.03.002
  9. Motzer RJ , Amsterdam A , Prieto V , Sheinfeld J , Murty VV , Mazumdar M , et al. Teratoma with malignant transformation: diverse malignant histologies arising in men with germ cell tumors. J Urol. 1998 Jan;159(1):133–8. https://doi.org/10.1016/S0022-5347(01)64035-7 DOI: https://doi.org/10.1016/S0022-5347(01)64035-7
  10. Oldenburg J , Alfsen GC , Waehre H , Fosså SD . Late recurrences of germ cell malignancies: a population-based experience over three decades. Br J Cancer. 2006 Mar;94(6):820–7. https://doi.org/10.1038/sj.bjc.6603014 DOI: https://doi.org/10.1038/sj.bjc.6603014
  11. Tandstad T , Kollmannsberger CK , Roth BJ , Jeldres C , Gillessen S , Fizazi K , et al. Practice Makes Perfect: The Rest of the Story in Testicular Cancer as a Model Curable Neoplasm. J Clin Oncol. 2017 Nov;35(31):3525–8. https://doi.org/10.1200/JCO.2017.73.4723 DOI: https://doi.org/10.1200/JCO.2017.73.4723
  12. Mosharafa AA , Foster RS , Koch MO , Bihrle R , Donohue JP . Complications of post-chemotherapy retroperitoneal lymph node dissection for testis cancer. J Urol. 2004 May;171(5):1839–41. https://doi.org/10.1097/01.ju.0000120141.89737.90 DOI: https://doi.org/10.1097/01.ju.0000120141.89737.90
  13. Subramanian VS , Nguyen CT , Stephenson AJ , Klein EA . Complications of open primary and post-chemotherapy retroperitoneal lymph node dissection for testicular cancer. Urol Oncol. 2010;28(5):504–9. https://doi.org/10.1016/j.urolonc.2008.10.026 DOI: https://doi.org/10.1016/j.urolonc.2008.10.026
  14. Winter C , Raman JD , Sheinfeld J , Albers P . Retroperitoneal lymph node dissection after chemotherapy. BJU Int. 2009 Nov;104(9b 9 Pt B):1404–12. https://doi.org/10.1111/j.1464-410X.2009.08867.x DOI: https://doi.org/10.1111/j.1464-410X.2009.08867.x
  15. Heidenreich A , Albers P , Hartmann M , Kliesch S , Kohrmann KU , Krege S , et al.; German Testicular Cancer Study Group . Complications of primary nerve sparing retroperitoneal lymph node dissection for clinical stage I nonseminomatous germ cell tumors of the testis: experience of the German Testicular Cancer Study Group. J Urol. 2003 May;169(5):1710–4. https://doi.org/10.1097/01.ju.0000060960.18092.54 DOI: https://doi.org/10.1097/01.ju.0000060960.18092.54
  16. Rosenvilde JJ , Pedersen GL , Bandak M , Lauritsen J , Kreiberg M , Wagner T , et al. Oncological outcome and complications of post-chemotherapy retroperitoneal surgery in non-seminomatous germ cell tumours - a systematic review. Acta Oncol. 2021 Jun;60(6):695–703. https://doi.org/10.1080/0284186X.2021.1905176 DOI: https://doi.org/10.1080/0284186X.2021.1905176
  17. Wells H , Hayes MC , O’Brien T , Fowler S . Contemporary retroperitoneal lymph node dissection (RPLND) for testis cancer in the UK - a national study. BJU Int. 2017 Jan;119(1):91–9. https://doi.org/10.1111/bju.13569 DOI: https://doi.org/10.1111/bju.13569
  18. Cary C , Masterson TA , Bihrle R , Foster RS . Contemporary trends in postchemotherapy retroperitoneal lymph node dissection: additional procedures and perioperative complications. Urol Oncol. 2015 Sep;33(9):389.e15–21. https://doi.org/10.1016/j.urolonc.2014.07.013 DOI: https://doi.org/10.1016/j.urolonc.2014.07.013
  19. Dindo D , Demartines N , Clavien PA . Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004 Aug;240(2):205–13. https://doi.org/10.1097/01.sla.0000133083.54934.ae DOI: https://doi.org/10.1097/01.sla.0000133083.54934.ae
  20. Vather R , Trivedi S , Bissett I . Defining postoperative ileus: results of a systematic review and global survey. J Gastrointest Surg. 2013 May;17(5):962–72. https://doi.org/10.1007/s11605-013-2148-y DOI: https://doi.org/10.1007/s11605-013-2148-y
  21. Macleod LC , Rajanahally S , Nayak JG , Parent BA , Ramos JD , Schade GR , et al. Characterizing the Morbidity of Postchemotherapy Retroperitoneal Lymph Node Dissection for Testis Cancer in a National Cohort of Privately Insured Patients. Urology. 2016 May;91:70–6. https://doi.org/10.1016/j.urology.2016.01.010 DOI: https://doi.org/10.1016/j.urology.2016.01.010
  22. Heidenreich A , Haidl F , Paffenholz P , Pape C , Neumann U , Pfister D . Surgical management of complex residual masses following systemic chemotherapy for metastatic testicular germ cell tumours. Ann Oncol. 2017 Feb;28(2):362–7. https://doi.org/10.1093/annonc/mdw605 DOI: https://doi.org/10.1093/annonc/mdw605
  23. Haarsma R , Blok JM , van Putten K , Meijer RP . Clinical outcome of post-chemotherapy retroperitoneal lymph node dissection in metastatic nonseminomatous germ cell tumour: A systematic review. Eur J Surg Oncol. 2020 Jun;46(6):999–1005. https://doi.org/10.1016/j.ejso.2020.02.035 DOI: https://doi.org/10.1016/j.ejso.2020.02.035
  24. Cary C , Foster RS , Masterson TA . Complications of Retroperitoneal Lymph Node Dissection. Urol Clin North Am. 2019 Aug;46(3):429–37. https://doi.org/10.1016/j.ucl.2019.04.012 DOI: https://doi.org/10.1016/j.ucl.2019.04.012
  25. Beck SD , Foster RS , Bihrle R , Ulbright T , Koch MO , Wahle GR , et al. Teratoma in the orchiectomy specimen and volume of metastasis are predictors of retroperitoneal teratoma in post-chemotherapy nonseminomatous testis cancer. J Urol. 2002 Oct;168(4 Pt 1):1402–4. https://doi.org/10.1016/S0022-5347(05)64458-8 DOI: https://doi.org/10.1016/S0022-5347(05)64458-8
  26. Steyerberg EW , Vergouwe Y , Keizer HJ , Habbema JD , Group RS ; ReHiT Study Group . Residual mass histology in testicular cancer: development and validation of a clinical prediction rule. Stat Med. 2001 Dec;20(24):3847–59. https://doi.org/10.1002/sim.915 DOI: https://doi.org/10.1002/sim.915
  27. Carver BS , Bianco FJ Jr , Shayegan B , Vickers A , Motzer RJ , Bosl GJ , et al. Predicting teratoma in the retroperitoneum in men undergoing post-chemotherapy retroperitoneal lymph node dissection. J Urol. 2006 Jul;176(1):100–3. https://doi.org/10.1016/S0022-5347(06)00508-8 DOI: https://doi.org/10.1016/S0022-5347(06)00508-8
  28. Albers P , Weissbach L , Krege S , Kliesch S , Hartmann M , Heidenreich A , et al.; German Testicular Cancer Study Group . Prediction of necrosis after chemotherapy of advanced germ cell tumors: results of a prospective multicenter trial of the German Testicular Cancer Study Group. J Urol. 2004 May;171(5):1835–8. https://doi.org/10.1097/01.ju.0000119121.36427.09 DOI: https://doi.org/10.1097/01.ju.0000119121.36427.09
  29. Fosså SD , Qvist H , Stenwig AE , Lien HH , Ous S , Giercksky KE . Is postchemotherapy retroperitoneal surgery necessary in patients with nonseminomatous testicular cancer and minimal residual tumor masses? J Clin Oncol. 1992 Apr;10(4):569–73. https://doi.org/10.1200/JCO.1992.10.4.569 DOI: https://doi.org/10.1200/JCO.1992.10.4.569

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