B. Lillaz

[Surgical resection of a massive residual retroperineal mass after chemotherapy in non-seminomatous germ cell tumor of the testis: a borderline case].

Background According to the last EAU Guidelines about testicular cancer, surgical resection of residual masses after chemotherapy in NSGCT is indicated in the case of visible residual masses and when serum levels of tumor markers are normal or normalizing. If markers are not normalized and when several chemotherapeutic regimens have failed to cure metastatic disease, resection of residual tumors (so called “desperation surgery”) should be offered to these patients. Methods We are going to present the case of a 30-year-old patient, affected by metastatic NSGCT. According to the prognostic-based staging system for metastatic germ cell cancer, our patient was in the poor prognosis group. The retroperitoneal mass involved all major vascular structures and still caused a bilateral obstruction of the upper urinary tract. Histological examination after radical orchiectomy revealed embryonal carcinoma and immature teratoma. The patient underwent a four-cycle VIP chemotherapy and then salvage chemotherapy with four cycles of TIP. After chemotherapy, the patient still presented large multiple metastatic localizations. Tumor markers were reduced but not normalized. The patient was then proposed for the resection of residual tumor. The residual mass could not be dissected from the left renal pedicle, so the left nephrectomy was unavoidable. The mass was hardly detached from vena cava and aorta. A bilateral iliac and retroperitoneal lymphadenectomy was performed. At the end of the procedure, the retroperitoneal space was completely free. Results Post-operative hospital stay was regular. A CT scan performed 3 months after the procedure did not show any residual lesion in the retroperitoneum. Three and six months later, the patient underwent the residual tumor resection of the right mediastinum and then of the left mediastinum and supraclavear metastases. Afterwards the patient underwent an EP consolidation chemotherapy. The patient is alive, 12 months after the retroperitoneal surgery. Conclusions Our experience confirms that resection of residual tumors is safe and feasible also in cases of very large abdominal disease.

Inferior vena cava prosthetic replacement in a patient with horseshoe kidney and metastatic testicular tumor: technical considerations and review of the literature

BackgroundSeminomatous and non-seminomatous Germ Cell Tumors (GCT) of the testis are a rare cancer, with an estimated incidence of 56.3 per million white males and 10 per million black males in the United States.The association between non-seminomatous GCT and horseshoe kidney is a rare event and is seen in about 1.3% of patients requiring retroperitoneal lymph node dissection. To our knowledge, no cases have been reported in which replacement of the IVC was also necessary.Case presentationWe report the case of a 22-year-old man with horseshoe kidney and metastatic non-seminomatous germ cell tumor involving the wall of the inferior vena cava.Following post-chemotherapy retroperitonal lymph node dissection, the inferior vena cava was replaced with an expanded polytetrafluoroethylene graft.At 2-years follow-up, the patient was in good health and the graft was patent. No clinical or diagnostic signs of renal impairment or recurrence of neoplastic disease were noted.ConclusionRadical surgery is warranted in patients with non-seminomatous germ cell tumor metastasizing to the retroperitoneal lymph nodes. When vena cava replacement is required, and the situation is further complicated by horseshoe kidney, as in this case, surgical technique will rely on multidisciplinary surgical treatment planning by a team composed of urologists, vascular surgeons and oncologists.