Retroperitoneal, Para-aortocaval Lymphatic Resection as the Surgical Treatment of Choice in Seminoma Grade II

Abstract

Background

Testicular cancer remains one of the most common malignant diseases in young men. The highest incidence was seen in the ages of 25-29 years. A significant part of them come from germ cell tumors, which are divided into seminoma and non-seminoma. Although the aggressiveness of tumors with germ cells remains high, it should be noted that there is a very high response to surgical and chemotherapeutic treatment, where a 5-year disease-free survival is evident in more than 95% of cases. The metastatic spread of these tumors follows the lymphatic drainage of the testes. The retroperitoneal and pre-aortocaval spread, which are resistant to chemotherapy, requires the intervention of an extended surgical procedure, which consists in the removal of the lymph nodes in these regions. The purpose of this procedure is the resection of pre-aortocaval lymph nodes remaining after orchidectomy, a procedure which represents one of the major components of the curative treatment.

Case presentation

There are three cases of patients, aged 37/32/39-years-old, who have undergone the surgical procedure of right orchidectomy. The biopsy obtained after the surgical intervention showed grade II seminoma. All three patients, who underwent orchidectomy in different years, were subjected to chemotherapeutic treatment with the 3 preparations bleomycin, etoposide and cisplatin. After that, for a period of 1.5-2 years, they carried out occasional checks, which they then stopped. The lack of control for a 5-year period, as well as the limitation of the surgical procedure only in the right orchidectomy, has led to the metastasis of the seminoma in the pre-aortocaval region. In this study, we consider the fact of performing the retroperitoneal lymphatic drainage procedure according to the lymphatic drainage route of the tests, in the cases of the biopsy result "Seminoma grade II" and above, as one of the major components of the curative treatment in addition to Chemotherapeutic treatment.

Discussion

The implementation of retroperitoneal, pre-aortocaval lymphadenectomy is considered mandatory, especially in the results of "Seminoma grade II" biopsy. In cases where laboratory and imaging examinations indicate residual retroperitoneal, pre-aortocaval masses, the surgical procedure of lymphadenectomy should be performed as soon as possible. The principle of the lymphadenectomy according to the way of drainage of the testes is important when we talk about oncological principles. Statistical data show the advantage of the extended surgical procedure, consisting of a disease-free survival period of 5 years at a rate of 95%. The choice of the retroperitoneal lymphadenectomy procedure has resulted in the normalization of tumor markers for at least a 2-year period after the intervention, also showing an improvement in the patient's prognosis.

Conclusion

In cases of histopathological response, where the result of Seminoma grade II and above is concluded, the surgical procedure should not be limited to simple orchidectomy or radical inguinal orchidectomy with the aim of avoiding metastatic spread along the lymphatic drainage route.

Keywords: General surgery, Testicular cancer, Seminoma, Para-aortocaval retroperitoneal lymphatic resection, RPLND.

DOI: 10.7176/ALST/95-06

Publication date: November 30^th 2022