Ann Thorac Surg 2000;69:1717-1721
© 2000 The Society of Thoracic Surgeons
Original articles: General thoracic
One-stage approach for retroperitoneal and mediastinal metastatic testicular tumor resection
Elie Fadel, MDa,
Bernard Court, MDa,
Alain R. Chapelier, MD, PhDa,
Jean Pierre Droz, MDa,
Philippe Dartevelle, MDa
a Department of Thoracic and Vascular Surgery and Heart-Lung Transplantation, Hôpital Marie-Lannelongue, Paris-Sud University, Le Plessis Robinson, France
Address reprint requests to Dr Fadel, Department of Thoracic and Vascular Surgery and Heart-Lung Transplantation, Hôpital Marie-Lannelongue, 133, Ave de la Resistance, 92350 Le Plessis Robinson, France
e-mail: eliefadel{at}lemel.fr
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Abstract
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Background. Eight percent of nonseminomatous germ cell tumors of the testis are associated with postchemotherapy residual masses in both the retroperitoneum and the posterior mediastinum. We describe a transabdominal transdiaphragmatic approach that allows simultaneous resection of these masses.
Methods. After standard retroperitoneal lymph node dissection through a midline laparotomy, an incision parallel to the right crus of the diaphragm was made and extended anteriorly through the muscular portion. Excellent exposure of the lower posterior mediastinum was obtained. Masses located higher than vertebra T8 were resected by extending this incision anteriorly and performing a partial sternal division. A complete median sternotomy can be done to allow subcarinal dissection, as well as pulmonary or anterior mediastinal mass resection.
Results. Between 1993 and 1999, 18 patients had simultaneous resection of retroperitoneal and posterior mediastinal masses with this approach. There were no perioperative deaths; 3 patients had minor postoperative complications. After a median follow-up of 3.2 years, the overall 5-year survival rate was 92%, and the 5-year disease-free survival rate was 87%.
Conclusions. The transdiaphragmatic approach to the posterior mediastinum is less aggressive than the thoracoabdominal approach. It is safe and effective for simultaneous resection of postchemotherapy testicular nonseminomatous germ cell tumors located in the retroperitoneum and posterior mediastinum.
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Introduction
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Nonseminomatous germ cell tumors of the testis are common malignancies in young men. Chemotherapy yields cure rates of up to 80% in metastatic cases [1]. Resection of all residual masses after chemotherapy is advocated [2–4]. The rationale for this aggressive approach is that residual masses can contain viable tumor cells and that removal of all tumor consolidates the effects of chemotherapy, allowing long-term survival [5, 6]. Moreover, in 8% of patients the retroperitoneal lymphatic drainage extends to the posterior mediastinum [7], usually along both sides of the descending thoracic aorta. We report a transabdominal transdiaphragmatic approach that permits simultaneous resection of residual masses located in the posterior mediastinum and retroperitoneum.
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Patients and methods
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Between March 1993 and January 1999, 36 men with nonseminomatous germ cell tumors of the testis underwent radical resection of postchemotherapy residual masses at Hôpital Marie-Lannelongue. Of those 36 patients, 18 had simultaneous resection of masses located in the retroperitoneum and in the lower posterior mediastinum using a one-stage transabdominal transdiaphragmatic approach. The median age was 29 years (range, 18 to 43 years). All 18 patients had inguinal orchidectomy before referral to our institution. Histologic findings are given in Table 1. Eight patients (44%) had had unsuccessful, radical, retroperitoneal lymph node dissection (n = 7) or retroperitoneal and mediastinal dissection through a thoracoabdominal approach (n = 1). The preoperative examination consisted of chest radiographs, cervico-thoraco-abdominal computed tomographic scans (Fig 1), spinal cord arteriography to identify the pattern of spinal cord blood supply, and assays of tumor markers (human and ß-human chorionic gonadotropin, 
-fetoprotein, and lactate dehydrogenase). All patients were given primary chemotherapy (4 cycles of cisplatin-based chemotherapy), and 2 patients subsequently received salvage chemotherapy preoperatively. One patient had received an autologous bone marrow transplant 2 months before referral. Preoperatively, tumor markers were elevated in 4 patients despite high-dose chemotherapy.
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Fig 1. Computed tomographic scan showing postchemotherapy residual masses in the lower posterior mediastinum on both sides of the descending thoracic aorta and in the retroperitoneum.
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Surgical technique
Central venous and arterial pressures were monitored. The patient was placed in the supine position. A midline incision was made from the xyphoid process to the pubis. A self-retaining ring retractor secured to the operating table was helpful for obtaining good exposure of the upper abdomen. After retroperitoneal lymph node dissection, the left lobe of the liver was grasped, and its attachments to the diaphragm were divided by cautery to a safe distance from the left hepatic vein. This lobe and the right costal margin were retracted together. The gastrohepatic ligament was opened through an avascular area above the lesser curvature of the stomach to provide entry into the lesser sac. The lower intraabdominal esophagus was encircled to provide future retraction at this level. The right crus of the diaphragm was then exposed. A paramedian incision of the right crus of the diaphragm was made and extended anteriorly through the muscular portion (Fig 2). The edges of the diaphragm were grasped using stay sutures. This provided direct exposure of the lower posterior mediastinum, including both sides of the descending aorta. Exposure was enhanced by intermittent cephalad retraction of the pericardium and heart. In most cases, the residual masses were easily separated from the aorta and fully resected. In all patients, the lumboaortic lymphatic drainage crossed the diaphragm through the two lesser apertures in each crus, following the greater and lesser splanchnic nerves, reaching the lower posterior mediastinum, and coursing laterally and posteriorly along the descending thoracic aorta (Fig 3). After resection, the diaphragm was repaired by using interrupted sutures of nonabsorbable material. Thoracic masses located higher than T8 were removed after an extension of the approach, as follows. The diaphragmatic incision was extended anteriorly toward the sternum, and partial sternal division was done. If necessary, a total median sternotomy was done to allow subcarinal dissection and resection of pulmonary wedges or anterior mediastinal masses. The posterior mediastinum was exposed through a transpericardial approach passing between the superior vena cava and the aorta.
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Fig 2. The lower posterior mediastinum is exposed after paramedian division of the right diaphragmatic crus extended anteriorly through the muscular portion. This exposes both sides of the descending aorta.
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Fig 3. The paraaortic and paracaval lymphatics below the renal arteries drain into the posterior mediastinum through the diaphragmatic crura, traveling through the two lesser apertures in each crus alongside the greater and the lesser splanchnic nerves, reaching the lower posterior mediastinum, and coursing lateral and posterior to the descending thoracic aorta.
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All results are expressed as the mean ± standard errors of the mean. Survival rates were calculated by life-table analysis. Kaplan-Meier curves were constructed.
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Results
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In 17 of 18 patients, all postchemotherapy residual masses were resected during a single procedure. The exception was a patient who had resection of liver metastasis at another institution 1 month after the retroperitoneal and mediastinal mass resection done at our institution. Permanent pathologic sections showed necrosis or mature teratoma in 14 patients and viable carcinoma in 3 other patients. The remaining patient had residual unresectable viable carcinoma in the neck over the brachial plexus. The patients with viable carcinoma had preoperative increases in tumor marker levels. The approach was extended to allow lung wedge resection in 7 patients, neck dissection in 5, subcarinal dissection in 5, and dissection of the anterior mediastinum in 2. A midline abdominal incision was used in all patients and a midline sternotomy in 5. In 3 of the first patients of the series, same-stage posterolateral thoracotomy was done to allow removal of subcarinal masses.
There were no perioperative deaths. For the entire procedure, the mean estimated blood loss was 1,330 ± 1,090 mL, and the mean operative time was 345 ± 99 minutes. The mean postoperative hospital stay was 14.4 ± 4.4 days. Three patients (17%) had one perioperative complication each: two developed chylothorax, which resolved with percutaneous drainage and a medium-chain triglyceride diet, and one had a peptic ulcer successfully treated with antihistamine drugs. Postoperatively, tumor markers remained elevated in 2 patients with residual viable carcinoma; one received additional chemotherapy and the other cervical radiation therapy and additional chemotherapy.
Postoperatively, patients were evaluated at 3-month intervals for 12 months and at 6-month intervals thereafter. Each evaluation included a physical examination and tumor marker assays. A computed tomographic scan was done 3 and 6 months postoperatively and annually thereafter. No patients were lost to follow-up.
During the study, the patient with viable carcinoma over the brachial plexus experienced rapid disease progression and died 21 months postoperatively despite radiation therapy and additional chemotherapy. Another patient had a hepatic recurrence after 26 months despite additional chemotherapy. His chemotherapy regimen was changed, and he was alive with disease 26 months later. Both these patients had elevated tumor markers at the time of and after the operation. After a median follow-up of 3.2 years, the overall 5-year survival rate was 92% (Fig 4), and the overall 5-year disease-free survival rate was 87% (Fig 5).
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Comment
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These results show that the transabdominal, transdiaphragmatic approach to the posterior mediastinum is safe and appropriate for simultaneous resection of postchemotherapy testicular nonseminomatous germ cell tumor metastases located in the retroperitoneum and lower posterior mediastinum.
Survival rates in metastatic nonseminomatous germ cell tumor of the testis have improved dramatically since the introduction of cisplatin-based chemotherapy [1]. Cure rates have ranged from 60% to 87% in recent studies [1, 8–10]. Resection of all masses after chemotherapy is advocated to reduce the risk of recurrence [2–4]. About 20% of resected masses have been found to contain viable tumor [9, 11], and incomplete tumor resection has been associated with poor prognosis [9, 12–14].
Nonseminomatous germ cell tumors of the testis occur in young men, of whom most are in good health, without severe cardiac or respiratory disorders [15]. Consequently, we and others [4] perform resection of all residual masses during a single surgical procedure. Three considerations support this strategy. First, operative morbidity is low, and there were no operative deaths in our cohort. Second, when residual masses contain viable tumor, a one-stage procedure allows the patient to have additional chemotherapy earlier. Differences in histologic findings at the thorax, abdomen, and neck have been reported in 25% to 46% of cases [4, 16, 17]; it follows that with multiple-stage procedures, postoperative chemotherapy is delayed if viable tumor is present only in the site operated on most recently. Third, one-stage procedures are associated with a shorter total hospital stay than multiple-stage operations.
Postchemotherapy metastases of nonseminomatous germ cell tumors of the testis are frequently located in the posterior mediastinum because the retroperitoneal lymphatics drain to this site [7]. In a large series of 1,000 postchemotherapy patients, Hejase and colleagues [7] found 80 patients with supradiaphragmatic mediastinal residual masses. In our study, the incidence of mediastinal metastases was higher because only patients with supradiaphragmatic extension are referred to our institution. The paraaortic and paracaval lymphatics below the renal arteries drain into the posterior mediastinum through the diaphragmatic crura. In our patients, we found that the invaded lymphatics traveled through the two lesser apertures in each crus, following the greater and the lesser splanchnic nerves, reached the lower posterior mediastinum, and finally coursed laterally and posteriorly to the descending thoracic aorta.
The proximity of the aorta and, above all, the fact that the spinal cord receives its blood supply (artery of Adamkiewicz) from the aorta between the T7 and L1 vertebrae [18] make radical resection of masses located in the lower posterior mediastinum a surgical challenge, particularly when the tumors are large [7]. Although anterior spinal artery syndrome has not been reported in this setting [19], probably because the patients are too young to have significant arteriosclerosis, we routinely performed spinal cord arteriography to identify the artery of Adamkiewicz. A few cases of paraplegia caused by anterior spinal artery thrombosis have been reported outside the setting of aortic aneurysm operations, namely, after posterolateral thoracotomy [20], spinal operations [21], or posterior mediastinal tumor resection [22]. Moreover, because the lymphatics course on both sides of the aorta, good exposure of the lower posterior mediastinum is mandatory to ensure radical and safe resection of residual masses.
This transabdominal, transdiaphragmatic approach to the posterior mediastinum offers the following advantages: there is only one skin incision, and consequently the operative time is dramatically reduced; the procedure is well tolerated by the patients; and the anterior aspect and both lateral aspects of the descending thoracic and abdominal aorta are exposed. The thoracoabdominal approach widely used for simultaneous thoracic and retroperitoneal resection [4, 7, 19] is a unilateral approach to the mediastinum and thorax and consequently does not offer direct and safe exposure of all sides of the aorta. Skinner and associates [19] reported a case of postoperative renovascular hypertension resulting from inadvertent ligation of an artery to the lower pole of the left kidney during an operation using the right thoracoabdominal approach; partial nephrectomy was subsequently done in that patient. The transabdominal, transdiaphragmatic approach to the posterior mediastinum provides direct exposure of the anterior aspect and both lateral aspects of the aorta. In all our patients, this approach allowed radical resection of postchemotherapy masses located in the lower posterior mediastinum without vascular injury; in particular, the artery of Adamkiewicz was carefully preserved, and there were no perioperative neurologic complications. Only 3 of our patients had masses on only one side of the aorta. In the other 15 patients, masses were present on both sides of the aorta, and in many cases both the aorta and the inferior vena cava were encircled by residual masses. Therefore, it is essential to have excellent and safe exposure of both vessels.
The transabdominal, transdiaphragmatic approach is less aggressive than the thoracoabdominal approach, which is associated with significant impairment of respiratory function [23]. It is a safe procedure, with low operative morbidity (only three minor complications) and without operative mortality in our series.
The transabdominal, transdiaphragmatic approach permits resection of masses located in the posterior mediastinum lower than vertebra T8. It can be extended if masses are present in the posterior mediastinum above this level. Furthermore, it can be combined with a sternolaparotomy in patients with anterior mediastinal or pulmonary masses, or with a cervicotomy in those with cervical masses. At the beginning of our experience, carinal masses were resected through a right posterolateral thoracotomy; we subsequently used sternolaparotomy with exposure of the posterior mediastinum through a transpericardial approach between the superior vena cava and the aorta.
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Accepted for publication December 18, 1999.
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Abstract
Introduction
