Surgical treatment of metastatic germ cell cancer

Abstract

Among young men between the ages of 15 and 40 years, germ cell cancer is the most common solid tumor [1]. The worldwide incidence of germ cell cancer is 70 000 cases. Compared to all solid tumors of men, germ cell cancer accounts for 1% of all male tumors. Nevertheless, the mortality of this rare tumor entity is about 13% since 9507 patients died worldwide of germ cell cancer. The improvement in survival of germ cell cancer patients is due to a multimodal treatment of germ cell cancer including cisplatin-based chemotherapy and surgery leading to higher cure-rates even in advanced stages [1], whereas the increasing incidence of germ cell cancers cannot be thoroughly explained. In this article we review the current indications for surgery in metastatic germ cell cancers, highlight the strength and weaknesses of techniques and indications and raise the question how to improve surgical treatment in metastatic germ cell cancer.

Keywords: Germ cell cancer; Metastatic germ cell cancer; Retroperitoneal lymphnode dissection; Retroperitoneal surgery.

Figure 1

Flow chart of treatment of germ cell cancer according to the NCCN and EAU Guideline [1,9]. The indications for surgery are highlighted (yellow). (A) The clinical and diagnostic work-up of seminoma patients; (B) The clinical and diagnostic work-up of non-seminoma patients. BEP, bleomycin, etoposide, cisplatin; EP, etoposied, cisplatin; PEI, cisplatin, etoposide, ifosfamide; FDG, fluorodeoxyglucose; PET, positron emission tomography; CT, computertomography; PC-RPLND, postchemotherapy retroperitoneal lymphnode dissection; ns-RPLND, nerve-sparing retroperitoneal lymphnode dissection; CS IS, clinical stage 1S; VIP, vinblastine, ifosfamide, cisplatin; N1-N3, lymphonodal metastasis WHO classification; NCCN, the National Comprehensive Cancer Network; EAU, the European Association of Urology. ∗preferred; ∗∗only selected cases.

Figure 2

Graphical description of anatomical boundaries of right and left template PC-RPLND. Template resection of the right side includes the precaval, caval, paracaval, retrocaval and inter-aortocaval regions, as well as the region lateral of the common iliac vessels. Template resection of the left side includes pre-aortic, retro-aortic and para-aortic lymph nodes. The ipsilateral ureter represents the caudal and lateral boundary of resection; in patients without retrocrural or suprahilar lymph nodes, the renal vein is described as the cranial and the crus of the diaphragma as the posterior resection boundary. PC-RPLND, post chemotherapy setting retroperitoneal lymphnode dissection.