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Wann ist die operative Versorgung von Metastasen beim testikulären Keimzelltumor angezeigt und gibt es eine wissenschaftliche Grundlage dafür?

When is surgical resection of metastases in testicular germ cell tumors indicated and is there a scientific basis?

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Zusammenfassung

Die Metastasenchirurgie stellt beim testikulären Keimzelltumor (KZT) einen integralen Bestandteil der kurativen Therapieoptionen dar. Dabei muss zwischen der primären retroperitonealen Lymphknotenchirurgie bei niedriger Metastasenlast in den klinischen Stadien I–IIB sowie der teils extensiven postchemotherapeutischen Residualtumorresektion (pRTR) unterschieden werden. Im klinischen Stadium I spielt die primäre, nervschonende retroperitoneale Lymphadenektomie (nsRPLA) beim nicht-seminomatösen Keimzelltumor (NSKZT) zumindest in Europa eine untergeordnete Rolle. Im klinischen Stadium IIA/B ist die nsRPLA eine leitlinienempfohlene Therapieoption bei negativen Tumormarkern, die mit einer Kurationsrate ohne weitergehende Chemotherapie assoziiert ist. Im klinischen Stadium IIA/B der Seminome stellt die retroperitoneale Metastasenresektion ein individuelles, noch experimentelles Vorgehen dar. Postchemotherapeutische Residualtumoren beim Seminom werden der Resektion bei einer Größe >3 cm und einer positiven Fluordesoxyglucose-Positronenemissionstomographie/Computertomographie- (FDG-PET/CT-)Aktivität zugeführt, um durch die komplette Resektion vitaler Residuen eine Kurationsrate von nahezu 100 % zu erreichen. Beim NSKZT ist die pRTR bei Residuen >1 cm indiziert, um die in bis zu 60 % der Patienten vorhandenen Teratom- und Karzinomanteile unter kurativer Intention entfernen zu können. Es ist eine komplette Resektion aller betroffenen lymphonodulären, vaskulären, viszeralen oder skeletalen Organstrukturen anzustreben, die aufgrund der Komplexität und der geringeren Morbiditäts- und Mortalitätsraten an tertiären Referenzzentren erfolgen sollte. In dem vorliegenden Artikel werden Indikation, Durchführung und Ergebnisse der Metastasenchirurgie beim KZT kritisch beleuchtet.

Abstract

Surgical resection of metastases represents an integral part of curative management in patients with testicular germ cell tumors (GCT). Primary nerve-sparing retroperitoneal lymph node dissection (nsRPLND) for low volume metastases in clinical stages I–IIB has to be differentiated from the more complex and more extensive postchemotherapeutic procedures. In Europe, primary nerve-sparing retroperitoneal lymph node dissection (nsRPLND) for clinical stage I nonseminomatous GCT (NSGCT) plays a subordinate. In clinical stage IIA/B, nsRPLND is indicated for patients with marker-negative metastases in whom cure rates of about 65% can be achieved with surgery alone. For clinical stage IIA/B seminomas, nsRPLND represents an individual, still experimental procedure with high cure rates. Postchemotherapy residual tumor resection (pRTR) for advanced seminomas is only indicated in the context of a FDG-PET/CT-positive residual mass >3 cm in diameter. For NSGCT, pRTR is indicated in patients with residual masses >1 cm and negative or plateauing tumor markers to resect persisting teratoma or vital cancer. Complete resection of all masses including resection of adjacent vascular, visceral or skeletal metastases is mandatory to achieving the highest cure rate possible. Due to the complexity and the lower rate of significant morbidity and mortality, these procedures should be done at tertiary referral centers.

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  1. Klinik für Urologie, Uro – Onkologie, Roboter-assistierte und Spezielle Urologische Chirurgie, Universitätsklinik Köln, Kerpener Str. 62, 50937, Köln, Deutschland

    A. Heidenreich, P. Paffenholz, F. Haidl & D. Pfister

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Heidenreich, A., Paffenholz, P., Haidl, F. et al. Wann ist die operative Versorgung von Metastasen beim testikulären Keimzelltumor angezeigt und gibt es eine wissenschaftliche Grundlage dafür?. Urologe 56, 627–636 (2017). https://doi.org/10.1007/s00120-017-0385-5

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