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Indikation, Zeitpunkt und Ergebnisse der sekundären chirurgischen Entfernung von Residualtumoren beim Nichtseminom und Seminom

  • N. Jaeger
  • L. Weißbach
  • J. H. Hartlapp
Conference paper

Zusammenfassung

Dank der Entwicklung neuartiger zytostatischer Substanzen hat die induktive Polychemotherapie die unbefriedigende Metastasenchirurgie als Initialmaßnahme in den Stadien des fortgeschritten disseminierten Keimzelltumors abgelöst. In Abhängigkeit von Tumorvolumen, Organbefall und histologischer Zusammensetzung der Geschwulst können Volkemissionen in 80% der Fälle und mehr erzielt werden. Für diese Patienten erübrigt sich jede weitere Operation; in Fällen einer Teilremission hat die Metastasenchirurgie dagegen nach wie vor diagnostischen, therapeutischen und prognostischen Stellenwert. Die Frage, ob in besonderen Situationen (reines Seminom bzw. teratomfreier Primärtumor) auf die Exploration verzichtet werden kann, wird sich durch prospektive Studien klären lassen.

Angesichts der Erfahrung, daß sich das Tumormarkerprofil häufig bereits nach dem 2. oder 3. chemotherapeutischen Zyklus normalisiert, sollte die operative Entfernung von Residuen so früh wie möglich vorgenommen werden. Offensichtlich führen zusätzliche Zyklen zu einer verstärkten Fibrosierung im Retroperitoneum und damit zum erhöhten Schwierigkeitsgrad des Eingriffs.

Der Vergleich von Ergebnissen einer multimodalen Therapie (induktive Chemotherapie + sekundäre Salvage-Operation) ist nur unter Berücksichtigung einer Subklassifikation des fortgeschrittenen Tumorstadiums zulässig. Vorgezeigte Daten zeigen, daß Patienten mit großem Tumorvolumen (“Advanced Disease” nach der Indiana-Klassifikation) schlechte Heilungsaussichten haben. Es handelt sich um ein Erkrankungsstadium, dessen Prognose offensichtlich durch Intensivierung der induktiven Chemotherapie verbessert werden kann.

Abstract

Thanks to the development of novel cytostatic agents, inductive polychemotherapy has displaced the unsatisfactory surgery of metastases as the initial measure in stages of advanced, disseminative germ cell tumors. Depending on tumor volume, organ involvement, and histological composition of the tumor, complete remissions can be attained in 80% of cases and more. Any further operation is unnecessary in these patients; on the other hand, in cases of partial remission, metastasis surgery still has diagnostic, therapeutic, and prognostic value. The question as to whether the exploration can be dispensed with in special situations (pure seminoma or teratoma-free primary tumor) will be clarified by prospective studies.

In view of the finding that the tumor marker profile normalizes as early as after the second or third cycle of chemotherapy, surgical resection of residual tumor should be formed as early as possible. Additional cycles evidently lead to increased fibrosis in the retroperitoneum and, thus to increased difficulty of operation.

Comparison of results of multimodal therapy (inductive chemotherapy plus secondary salvage operation) is only possible when subclasses of the advanced tumor stage are taken into consideration. The data show that patients with a large tumor volume (“advanced disease”, according to the Indiana classification) have poor prospects of healing. This is a stage of the disease in which the prognosis can evidently be improved by intensification of inductive chemotherapy.

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Literatur

  1. 1.
    Birch R, Williams SD, Cone A, Einhorn L, Roark P, Turner S, Greco FA (1986) Prognostic Factors for favourable Outcome in Disseminated Germ Cell Tumors. J Clin Oncol 4: 400–407PubMedGoogle Scholar
  2. 2.
    Ball D, Barett A, Peckham MJ (1982) The Management of Metastatic Seminoma Testis. Cancer 50: 2289–2294PubMedCrossRefGoogle Scholar
  3. 3.
    Bosl GJ, Gluckman R, Geller NL, Golbey RB, Whitmore WF, Herr H, Sogani P, Morse M, Martini N, Bains M, McCormick P (1986) VAB-6: An Effective Chemotherapy Regimen for Patients with Germ Cell Tumors. J Clin Oncol 4: 1493–1499PubMedGoogle Scholar
  4. 4.
    Caldwell CWL, Kademian MT, Frias Z, Davis E (1980) The Management of Testicular Seminomas. Cancer 45: 1768–1774PubMedGoogle Scholar
  5. 5.
    Crawford ED (1984) The Southwest Oncology Group Study for Advanced Testicular Cancer. Sem Urol 2: 244–253Google Scholar
  6. 6.
    Daniels JR (1985) Chemotherapy in Seminoma: When is it Appropriate Initial Treatment? J Clin Oncol 3: 1294–1295PubMedGoogle Scholar
  7. 7.
    Donohue JP, Einhorn LH, Williams SD (1980) Cytoreductive Surgery for Metastatic Testis Cancer: Considerations of Timing and Extent. J Urol 123: 876–880PubMedGoogle Scholar
  8. 8.
    Donohue JP, Rowland RG (1984) The Role of Surgery in Advanced Testicular Cancer. Cancer 54: 2716–2721PubMedCrossRefGoogle Scholar
  9. 9.
    Donohue JP (1987) Selectin Initial Therapy (Seminoma and Nonseminoma). Cancer 60: 490–495PubMedCrossRefGoogle Scholar
  10. 10.
    Donohue JP, Rowland RG, Kopecky K, Steidle CP, Geier G, Ney KG, Einhorn LH, Williams SD, Loehrer P (1987) Correlation of Computerized Tomographic Changes and Histological Findings in 80 Patients Having Radical Retroperitoneal Lymph Node Dissection after Chemotherapy for Testis Cancer. J Urol 137: 1176–1179PubMedGoogle Scholar
  11. 11.
    Einhorn LH, Williams SD (1980) Chemotherapy of Disseminated Testicular Cancer: A Random Prospective Study. Cancer 46: 1339–1344PubMedCrossRefGoogle Scholar
  12. 12.
    Einhorn LH (1987) Chemotherapy of Disseminated Germ Cell Tumors. Cancer 60: 570–573PubMedCrossRefGoogle Scholar
  13. 13.
    Friedman EL, Garnick MB, Stomper PC, Mauch PM, Harrington DP, Richie JP (1985) Therapeutic Guidelines and Results in Advanced Seminoma. J Clin Oncol 3: 1325–1332PubMedGoogle Scholar
  14. 14.
    Gallmeier WM, Kaiser G, Bruntsch U (1984) Chemotherapie bei Nicht-Seminom-Hodenkar-zinomen. Münch med Wschr 126: 14–19Google Scholar
  15. 15.
    Garnick MB, Canellos GP, Richie JP (1980) Advanced Testicular Carcinoma: Correlation of Radiographic and Surgical Findings Following Combination Chemotherapy. Proc Am Soc Clin Oncol 21: 422Google Scholar
  16. 16.
    Geldermann WAH, Schraffordt-Koops H, Sleijfer DT, Oosterhuis JW, Oldhoff J (1986) Treatment of Retroperitoneal Residual Tumor after PVB Chemotherapy of Nonseminomatous Testicular Tumors. Cancer 58: 1418–1421CrossRefGoogle Scholar
  17. 17.
    Jaeger N, Weißbach L, Altwein JE, Kreuser E (1983) Primary lymphadenectomy or primary chemotherapy in Advanced Metastastic Testicular Cancer. Eur Urol 9: 329–333PubMedGoogle Scholar
  18. 18.
    Jaeger N, Weißbach L, Vahlensieck W (1984) Second-Look Lymphadenectomy in the Treatment of Germ Cell Testis Tumors. Eur Urol 10: 10–16PubMedGoogle Scholar
  19. 19.
    Jaeger N, Vahlensieck W (1985) Diagnostic Value of Markers AFP, HCG and LDH in Advanced Germ Cell Tumors before and after Cytostasis resp. In: Khoury S, Küss R, Murphy GP, Chatelain C, Karr JP (Hrsg) Testicular Cancer, Alain R Liss, Inc. (Progress in Clinical and Biological Research, Volume 203, pp. 107–112)Google Scholar
  20. 20.
    Jaeger N, Kreuser ED, Altwein JE, Vahlensieck W (1987) Zeitpunkt und Ausmaß der verzögerten Resektion beim fortgeschrittenen Keimzelltumor (T0_4N3,4M0,1). Akt Urol 18: 171–176CrossRefGoogle Scholar
  21. 21.
    Loehrer PJ, Hui S, Clark S, Seal M, Einhorn LH, Williams SD, Ulbright T, Mandelbaum I, Rowland R, Donohue JP (1986) Teratoma following Cisplatin-based combination Chemotherapy for Nonseminomatous Germ Cell Tumors: A Clinicopathological Correlation. J Urol 135: 1183–1189PubMedGoogle Scholar
  22. 22.
    Logothetis CJ, Samuels ML (1984) Surgery in The Management of Stage III Germinal Cell Tumors. Cancer Treat Rev 11: 27–37PubMedCrossRefGoogle Scholar
  23. 23.
    Logothetis CJ, Samuels ML, Selig D, Swanson D, Johnson DE, von Eschenbach AC (1985) Improved Survival with Cyclic Chemotherapy for Nonseminomatous Germ Cell Tumors of the Testis. J Clin Oncol 3: 326–335PubMedGoogle Scholar
  24. 24.
    Logothetis CJ, Samuels ML, Selig D, Ogden S, Dexeus F, Swanson D, Johnson D, von Eschenbach A (1986) Cyclic Chemotherapy with Cyclophosphamide, Doxorubicin and Cisplatin Plus Vinblastine and Bleomycin in Advanced Germinal Tumors. Am J Med 81: 219–228PubMedCrossRefGoogle Scholar
  25. 25.
    Neidhart JA, Memo R, Metz EN, Wise H (1980) Probable cure of Metastatic Testicular Tumors treated with Sequential Therapy. Cancer Treat Rep 64: 553–554PubMedGoogle Scholar
  26. 26.
    Peckham MJ, Barrett A, Liew KH, Horwich A, Robinson B, Dobbs HJ, McElwain TJ, Hendry WF (1983) The Treatment of Metastatic Germ Cell Testicular Tumours with Bleomycin, Etoposide and Cisplatin (BEP). Br J Cancer 47: 613–619PubMedCrossRefGoogle Scholar
  27. 27.
    Peckham MJ, Horwich A, Hendry WF (1985) Treatment with Cisplatinbased combination chemotherapy or Carboplatin. Br J Cancer 52: 7–13PubMedCrossRefGoogle Scholar
  28. 28.
    Pizzocaro G, Salvioni R, Pasi M, Zanoni F, Milani A, Pilotti S, Monfardini S (1985) Early Resection of Residual Tumor During Cisplatin, Vinblastine, Bleomycin Combination Chemotherapy in Stage III and Bulky Stage II Nonseminomatous Testicular Cancer. Cancer 56: 249–255PubMedCrossRefGoogle Scholar
  29. 29.
    Prenger K, Eysman L, Homan van der Heide JN, Oldhoff J, Sleijfer DT, Schraffordt-Koops H, Oosterhuis JW (1984) Thoracotomy as a Staging Procedure after Chemotherapy in the Treatment of Stage III Nonseminomatous Carcinoma of the Testis. Ann Thorac Surg 38: 444–446PubMedCrossRefGoogle Scholar
  30. 30.
    Schuette J, Niederle M, Scheulen ME, Seeber S, Schmidt CG (1985) Chemotherapy of Metastatic Seminoma. Br J Cancer 51: 467–472PubMedCrossRefGoogle Scholar
  31. 31.
    Seeber S (1982) Fortschritte in der Therapie teratoider Hodentumoren. Wien Med Wschr 13: 329–333Google Scholar
  32. 32.
    Skinner DG, Melamud A, Lieskovsky G (1982) Complications of thoracoabdominal retroperitoneal Lymph Node Dissection. J Urol 127: 1107–1110PubMedGoogle Scholar
  33. 33.
    Smith RB, DeKernion JB, Skinner DB (1979) Management of Advanced Testicular Seminoma. J Urol 121: 429–431PubMedGoogle Scholar
  34. 34.
    Stanton GF, Bosl GJ, Whitmore WF, Herr H, Sogani P, Morse M, Golbey RB (1985) VAB-6 as Initial Treatment of Patients with Advanced Seminoma. J Clin Oncol 3: 336–339PubMedGoogle Scholar
  35. 35.
    Stomper PC, Jochelson MS, Friedman EL, Garnick MB, Richie JP (1986) CT Evaluation of Advanced Seminoma Treated with Chemotherapy. AJR 146: 745–748PubMedGoogle Scholar
  36. 36.
    Stoter G, Vendrick GPJ, Struyvenberg A, Sleijfer DT, Vriesendrop R, Schrafford-Koops H, van Ostertom AT, ten Bokkel-Huinink WW, Pinedo HM (1984) Five year survival of patients with disseminated nonseminomatous testicular cancer treated with cisplatin, vinblastine and bleomycin. Cancer 54: 1521–1526PubMedCrossRefGoogle Scholar
  37. 37.
    Suurmeijer AJH, Oosterhuis JW, Sleijfer DT, Schrafford-Koops H, Fleuren GJ (1984) Nonseminomatous germ cell tumours of the testis: Morphology of retroperitoneal lymph node metastases after chemotherapy. Eur J Cancer Clin Oncol 20: 727–734PubMedCrossRefGoogle Scholar
  38. 38.
    Vugrin D, Whitmore WF, Sogani PC, Bains M, Herr HW, Golbey RB (1981) Combined chemotherapy and surgery in treatment of advanced germ cell tumors. Cancer 47: 2228–2234PubMedCrossRefGoogle Scholar
  39. 39.
    Vugrin D, Whitmore WF, Golbey RB (1982) Vinblastine, Actinomycin-D, Bleomycin, Cyclophosphamide and Cisplatin Combination chemotherapy in metastatic testis cancer — A 1 year program. J Urol 128: 1205–1208PubMedGoogle Scholar
  40. 40.
    Vugrin D, Whitmore WF (1985) The Role of Chemotherapy and Surgery in the Treatment of Retroperitoneal Metastases in Advanced Nonseminomatous Testis Cancer. Cancer 55: 1874–1878PubMedCrossRefGoogle Scholar
  41. 41.
    Weißbach L, Boedefeld EA, Seeber S (1985) Hodentumoren: Frühzeitige Diagnose und stadiengerechte Therapie sichern den Erfolg. Deutsches Ärzteblatt 82: 1340–1349Google Scholar
  42. 42.
    Wettlaufer JN (1984) The management of Advanced Seminoma. Sem Urol 2: 257–263Google Scholar
  43. 43.
    Wettlaufer JN, Feiner AS, Robinson WA (1984) Vincristine, Cisplatin and Bleomycin with Surgery in the Management of Advanced Metastatic Nonseminomatous Testis Tumors. Cancer 53: 203–209PubMedCrossRefGoogle Scholar
  44. 44.
    Williams S, Einhorn LH, Greco A, Birch R, Irwin L (1985) Disseminated germ cell tumors: A comparison of Cisplatin plus Bleomycin plus either Vinblastine (PVB) or VP-16 (BEP). Proc Amer Soc Clin Oncol 4: 100Google Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 1988

Authors and Affiliations

  • N. Jaeger
  • L. Weißbach
  • J. H. Hartlapp

There are no affiliations available

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