Management of the post-chemotherapy residual mass in patients with advanced stage non-seminomatous germ cell tumors (NSGCT).

Since it is difficult to predict the probability of persistent teratoma or of a viable tumor in patients with normalized tumor markers and a normal CT scan following chemotherapy for advanced stage testis cancer, recommendations regarding adjunctive surgery have ranged from observation to surgical exploration for all patients. Suggested variables for patients in whom surgery can be omitted safely, include normal post-chemotherapy CT scans, residual abdominal masses of less than 1.5 cm, a 90% or greater decrease in the volume of the retroperitoneal mass with chemotherapy and no teratomatous elements in the orchiectomy specimen. In contrast, during several investigations, the application of the above mentioned criteria resulted in a false-negative prediction of approximately 20%. However, recognizing the morbidity of the operative procedure itself in addition to the fact that only 2-4% of patients will develop recurrent tumor confined to the retroperitoneal space that can then be managed surgically or by administration of further chemotherapy, secondary surgery should be avoided if a sufficient follow-up after chemotherapy is guaranteed. The extent of adjunctive surgery in patients revealing a residual tumor mass after first-line chemotherapy remains a subject of ongoing discussions. It has been indicated that extensive retroperitoneal surgery after chemotherapy is associated with significant clinical morbidity. A limitation of post-chemotherapy surgery to a resection of the residual mass with or without an additional modified template dissection appears to result in an acceptable frequency of retroperitoneal recurrences and a decreased complication rate.