Adjunctive surgical resection of residual disease after
chemotherapy is a critical part of the comprehensive management of patients with advanced
nonseminomatous germ-cell tumor (NSGCT). Surgical resection is indicated in the presence of residual radiographic abnormalities and normal serum
tumor markers.
Necrosis,
teratoma, and viable
carcinoma can be found at any resected site. After
induction chemotherapy,
necrosis comprises approximately 50% of histologic findings,
teratoma 40%, and viable GCT the remaining 10%. A number of investigators have attempted to predict the presence of
necrosis in an effort to obviate surgery. A number of variables predictive of
necrosis have been identified and tested prospectively, including: degree of
tumor shrinkage, size of pre- and posttreatment mass(es), prechemotherapy markers, and teratomatous components in the
orchiectomy specimen. However, the risk for a false-negative prediction remains approximately 20%. The most rigorous approach remains a retroperitoneal
lymph node dissection (RPLND). Furthermore, the histologic discordance between different sites ranges from 29% to 46%; thus, all sites of residual disease should be resected. The patient's prognosis is influenced by: (1) completeness of resection, and (2) biology of the
tumor (histology of residual mass(es), marker status at the time of RPLND, and prior burden of
therapy). Surgical boundaries and completeness of dissection should not be compromised in an attempt to preserve ejaculation.