What's the next step for a patient with right testicular cancer, status post orchiectomy and Bleomycin, Etoposide, and Cisplatin (BEP) regimen, with interval enlargement of periaortic and retrocaval retroperitoneal adenopathy on Computed Tomography (CT) scan?

Management of Testicular Cancer with Enlarging Retroperitoneal Adenopathy Post-BEP

For a patient with right testicular cancer post-orchiectomy and BEP chemotherapy who has enlarging retroperitoneal adenopathy, surgical resection of the residual mass is strongly recommended as the next step in management.

Assessment of Current Situation

The patient presents with:

• Right testicular cancer status post orchiectomy
• Completed BEP (Bleomycin, Etoposide, Cisplatin) chemotherapy
• CT CAP showing interval enlargement of periaortic and retrocaval retroperitoneal adenopathy
  • Largest mass measuring 6.6 × 6.3 cm (previously 5.8 × 5.2 cm)
  • Mass effect on IVC without thrombosis

Management Algorithm

1. Surgical Management (Primary Recommendation)

• Surgical resection of residual retroperitoneal mass is mandatory since:

  • The mass is >1 cm in diameter (6.6 × 6.3 cm)
  • The mass has shown interval enlargement on imaging
  • This is standard management for nonseminomatous germ cell tumors (NSGCT) post-chemotherapy 1

• Timing of surgery:

  • Should be performed within 6-8 weeks after the last chemotherapy cycle 1
  • Delay could risk further growth and potential complications from mass effect on IVC

• Surgical approach:

  • Bilateral nerve-sparing retroperitoneal lymph node dissection (RPLND) is the standard option
  • Should be performed at a specialized testicular cancer center by an experienced surgeon 1

2. Post-Surgical Management

Management depends on pathological findings:

1. If necrosis/fibrosis only:

   • No further therapy needed
   • Continue surveillance 1

2. If mature teratoma only:

   • No further therapy needed
   • Continue surveillance 1

3. If viable germ cell tumor elements found:

   • Consider additional chemotherapy (2 cycles of EP, VeIP, or TIP) 1
   • Especially if >10% viable tumor in the specimen 1

3. If Surgery Not Feasible

If the patient has contraindications to surgery:

• Consider second-line chemotherapy regimens:
  • VeIP (Vinblastine, Ifosfamide, Cisplatin)
  • TIP (Paclitaxel, Ifosfamide, Cisplatin) 1
• Consider clinical trial participation if available 1

Important Considerations

1. Tumor Markers:

   • Serum tumor markers (AFP, β-HCG) should be assessed before surgery
   • If markers are elevated, this suggests active disease and may influence management 1

2. Specialized Care:

   • Management should occur at a center with expertise in testicular cancer 1
   • Retroperitoneal surgery requires specialized surgical expertise

3. Potential Complications:

   • Mass effect on IVC increases risk of venous thromboembolism
   • Consider thromboprophylaxis 1
   • Avoid central venous access devices when possible 1

4. Imaging Considerations:

   • PET scans have limited predictive value for residual disease in nonseminoma 1
   • CT imaging remains the standard for follow-up

Common Pitfalls to Avoid

1. Delaying surgical intervention - Growing masses should be resected promptly to prevent further complications from mass effect

2. Incomplete resection - All visible disease should be removed; incomplete resection is associated with poorer outcomes

3. Inappropriate surgical approach - Laparoscopic or robotic approaches should only be considered in highly selected cases by surgeons with extensive experience 1

4. Observation alone - For nonseminoma with residual masses >1 cm, observation without resection carries a 6-9% risk of recurrence 1

5. Failure to consider histology - Management differs significantly based on the histological findings in the resected specimen

The enlarging retroperitoneal mass in this patient represents a clear indication for surgical intervention, which offers the best chance for definitive management and accurate histological assessment to guide further treatment decisions.