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Komplexe Residualtumoren nach Chemotherapie bei nichtseminomatösen Keimzelltumoren

Laparoskopisches Management – Grenzen und Chancen

Complex residual tumors after chemotherapy of nonseminomatous germ cell tumors

Laparoscopic management – limits and chances

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Zusammenfassung

Zweck

Die retroperitoneale Lymphadenektomie (RLA) ist die Therapie der Wahl bei Patienten mit metastasierendem Nichtseminom (NSGCT) nach Chemotherapie. Mit der Weiterentwicklung der laparoskopischen Operationstechnik können auch komplexere Residuen mittels laparoskopischer retroperitonealer Lymphadenektomie (L-RLA) behandelt werden. In dieser Studie zeigen wir die Machbarkeit und die Grenzen der Laparoskopie in der Behandlung komplexer Residuen.

Patienten und Methoden

Retrospektiv wurden 21 NSGCT- und Seminompatienten (Durchschnittsalter 29 Jahre) mit komplexen Gefäß- sowie intrathorakalen Residuen nach Chemotherapie eingeschlossen (klinisches Stadium IIA–IIIB). Alle Männer mit entsprechenden Residuen erhielten eine systematische bilaterale L-RLA zwischen 2009 und 2014. Bei 19 Patienten zeigte sich bildmorphologisch bzw. intraoperativ eine Beteiligung der infrarenalen großen Gefäße durch NSGCT-Residuen, bei 2 Patienten zeigten sich Residuen supradiaphragmal mit einer Größe von 5,4 sowie 7,0 cm. Positive Tumormarker nach Chemotherapie waren ein Ausschlusskriterium für die RLA. Ebenso ausgeschlossen wurden Patienten mit Lokalrezidiven nach vorangegangener offener RLA sowie Patienten mit exzessiver Gefäßbeteiligung.

Ergebnisse

Alle Patienten konnte ohne Konversion behandelt werden. Die mittlere Größe der Residuen nach Chemotherapie betrug 3,2 (1,5–9,7) cm. Der mittlere Blutverlust lag bei 294 (50–1000) ml, der mittlere Krankenhausaufenthalt dauerte 6 (3–9) Tage. Das mittlere Follow-up betrug 16 (1–37) Monate. Es traten im unmittelbaren postoperativen Verlauf keine perioperativen Komplikationen größer Grad II nach der Clavien-Dindo-Klassifikation auf. Ein Rezidiv konnte innerhalb des Beobachtungszeitraums nicht festgestellt werden.

Schlussfolgerung

Die L-RLA stellt eine sichere Alternative in der Behandlung komplexer Residuen mit vaskulärer Infiltration nach Chemotherapie beim Hodentumor dar. Die bilaterale L-RLA ist unter Gewährleistung onkologischer Prinzipien technisch machbar und reproduzierbar. Zudem konnte das Spektrum der Laparoskopie auf das intrathorakale Tumorgeschehen bei ausgewählten Patienten erweitert werden.

Abstract

Purpose

Laparoscopic retroperitoneal lymph node dissection (L-RPLND) is often required in patients with metastatic nonseminomatous germ cell tumors (NSGCT) and residual tumors after chemotherapy. Laparoscopy has become established as a safe procedure in the surgical management of these tumors. Due to the rapid development of laparoscopy, complex retroperitoneal and even intrathoracic residuals can also be treated in high volume centers.

Patients and methods

This study included 21 retrospectively identified NSGCT and seminoma patients (mean age 29 years) with metastatic disease and clinical stage (CS) IIA-IIIB. A bilateral L-RPLND was performed in all male patients between 2009 and 2014. In 19 patients an infiltration of the great vessels was detected during surgery and vascular reconstruction was necessary. In 2 patients an intrathoracic residual 5.4 cm and 7 cm in size, respectively, was diagnosed during follow-up. Exclusion criteria for L-RPLND were positive tumor markers after chemotherapy, patients with local recurrence after previous open L-RPLND and patients with excessive vascular involvement.

Results

In this series no conversions to open surgery were necessary. The mean tumor size post-chemotherapy was 3.6 cm (range 1.5-9.7 cm). The mean measured blood loss was 294 ml (range 50-1000 ml). The mean hospitalization time was 6 days (range 3-9 days) and mean follow-up was 16 months (range 1-37 months). No complications higher than grade II (Clavien-Dindo classification) were registered in the immediate postoperative course. During the follow-up period no in-field recurrences were registered.

Conclusion

The L-RPLND seems to be a safe alternative surgical procedure for certain complex residuals with vascular involvement after chemotherapy of testicular cancer. Bilateral L-RPLND is technically feasible and reproducible under guaranteed oncological principles. An infiltration of the great vessels and also intrathoracic residuals can be managed in selected patients without compromising the clinical and oncological course.

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Einhaltung ethischer Richtlinien

Interessenkonflikt. S. Aufderklamm, T. Todenhöfer, J. Hennenlotter, J. Mischinger, A. Sim, J. Böttge, S. Rausch, S. Bier, O. Halalsheh, A. Stenzl, G. Gakis und C. Schwentner geben an, dass kein Interessenkonflikt besteht. Alle im vorliegenden Manuskript beschriebenen Untersuchungen am Menschen wurden mit Zustimmung der zuständigen Ethik-Kommission, im Einklang mit nationalem Recht sowie gemäß der Deklaration von Helsinki von 1975 (in der aktuellen, überarbeiteten Fassung) durchgeführt. Von allen beteiligten Patienten liegt eine Einverständniserklärung vor.

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Authors and Affiliations

  1. Klinik für Urologie, Eberhard-Karls-Universität Tübingen, Hoppe-Seyler-Straße 3, 72076, Tübingen, Deutschland

    S. Aufderklamm, T. Todenhöfer, J. Hennenlotter, J. Mischinger, A. Sim, J. Böttge, S. Rausch, S. Bier, O. Halalsheh, A. Stenzl, G. Gakis &  C. Schwentner FEBU

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  1. S. Aufderklamm
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  2. T. Todenhöfer
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  3. J. Hennenlotter
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  4. J. Mischinger
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  5. A. Sim
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  6. J. Böttge
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  7. S. Rausch
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  8. S. Bier
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  9. O. Halalsheh
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  10. A. Stenzl
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  11. G. Gakis
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  12. C. Schwentner FEBU
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Correspondence to C. Schwentner FEBU.

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Aufderklamm, S., Todenhöfer, T., Hennenlotter, J. et al. Komplexe Residualtumoren nach Chemotherapie bei nichtseminomatösen Keimzelltumoren. Urologe 54, 1002–1009 (2015). https://doi.org/10.1007/s00120-014-3616-z

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  • DOI: https://doi.org/10.1007/s00120-014-3616-z

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