What is the recommended treatment for a 29-year-old man with a residual mass following chemotherapy for stage 3C non-seminomatous germ cell tumor (NSGCT)?

Management of Residual Mass After Chemotherapy for Stage 3C NSGCT

Surgical resection of the residual mass is mandatory for this 29-year-old man with stage 3C non-seminomatous germ cell tumor (NSGCT) who has a residual mass following chemotherapy. 1

Rationale for Surgical Intervention

• No diagnostic test or risk calculator can accurately predict the histology of residual masses in NSGCT patients after chemotherapy 1
• Resection is mandatory for all patients with a residual mass >1 cm in greatest diameter on cross-sectional imaging 1
• Histological findings in residual masses after first-line chemotherapy typically reveal necrosis/fibrosis (50%), mature teratoma (35%), or viable cancer (15%) 1
• Complete resection is an independent and consistent predictive variable of clinical outcome 1

Timing and Approach

• Surgery should be performed within 6-8 weeks after the last chemotherapy cycle 1
• Referral to a high-volume center is strongly recommended for surgical resection of post-chemotherapy masses 1
• A full bilateral template retroperitoneal lymph node dissection (RPLND) should be performed 1
• The boundaries of dissection should include the renal hilar vessels (superiorly), ureters (laterally), and common iliac arteries (inferiorly) 1

Surgical Considerations

• In post-chemotherapy RPLND, surgical margins should not be compromised in an attempt to preserve ejaculation 1
• The "split and roll" technique (where lumbar vessels are identified and sequentially ligated) allows resection of all lymphatic tissue around and behind the great vessels (aorta, IVC) and minimizes the risk of in-field recurrence 1
• Additional procedures and resection of adjacent structures may be required 1
• Nerve-sparing approaches should be considered when technically feasible, but oncological outcomes should not be compromised 2

Management of Multiple Residual Masses

• If technically feasible, all residual masses should be resected 1
• In patients with residual masses at multiple sites (retroperitoneal and extraretroperitoneal), an individual decision should be made regarding the number and extension of resections 1
• Surgery should generally commence at the site with the highest volume of residual disease 1
• Simultaneous resection of multiple sites (retroperitoneal, thoracic, cervical) can be considered in selected patients 3
• Discordance in histology is found in 35-50% of patients with multiple residual masses 1

Post-Surgical Management

• Management after resection depends on the histological findings:
  • If necrosis or mature teratoma is found, no further treatment is required 1
  • If viable carcinoma is found, the role of consolidation chemotherapy is equivocal 1
  • For patients with <10% viable tumor cells and complete resection, observation may be justified 1
  • If >10% viable cancer is found or if completeness of resection is in doubt, consolidation chemotherapy might be justified 1

Salvage Options for Recurrence

• For recurrence or progression after first-line treatment, salvage chemotherapy options include:
  • Four cycles of TIP (paclitaxel, ifosfamide, cisplatin) 1
  • Four cycles of VeIP (vinblastine, ifosfamide, cisplatin) 1
  • Four cycles of PEI/VIP (cisplatin, etoposide, ifosfamide) 1

Common Pitfalls and Caveats

• Laparoscopic or robotic RPLND should only be considered in specialist centers with expertise in both open RPLND and minimally invasive surgery 1
• Due to high treatment-related acute morbidity, surgery of residual masses should be performed only at specialized centers 1
• Patients with residual masses after salvage chemotherapy or high-dose chemotherapy have a greater risk of harboring active disease; surgery is indicated even for residual masses <1 cm in these cases 1
• Tumor markers should be normalized or normalizing before surgery; if markers continue to rise during or after chemotherapy, salvage chemotherapy rather than surgery should be considered 1
• Long-term follow-up with serum tumor markers and imaging is essential as late relapses can occur 1