Discordance of retroperitoneal and thoracic histologic findings in patients with metastatic germ cell tumors at postchemotherapy residual tumor resection.

INTRODUCTION AND OBJECTIVES: Postchemotherapy residual tumor resection (PC-RTR) is an important part of the multimodal treatment for patients with metastatic germ cell tumors. Simultaneous retroperitoneal and thoracic metastases often require consecutive surgical procedures. This study analyzes the histologic findings after abdominal and thoracic surgery in order to tailor the sequence and intensity of surgery. PATIENTS AND METHODS: From a total of 671 PC-RTRs from 2008 to 2021 we analyzed 50 patients with stage III non-seminomatous germ cell tumor (NSGCT) who had undergone both retroperitoneal and thoracic postchemotherapy residual tumor resection after first-line and salvage chemotherapy. RESULTS: All patients included had stage III NSGCT. 39 and 11 patients received first-line and salvage chemotherapy, respectively. 45 (90%) patients received retroperitoneal resection first, followed by thoracic surgery. Three patients (6%) underwent thoracic surgery before retroperitoneal surgery and two patients (4%) underwent simultaneous surgery. Overall, the histology of retroperitoneal and thoracic specimens was discordant in 23% of cases. After first-line chemotherapy, of fourteen patients with necrosis in retroperitoneal histology, four patients had vital carcinoma in lung histology. In patients with teratoma in the retroperitoneum, the thoracic findings were concordant in most cases (78%). When teratomatous elements were also present in the orchiectomy specimen, concordance was 100%. After salvage chemotherapy, the discordance rate was 55%. CONCLUSION: The data presented in this study underline that retroperitoneal residual masses with necrosis cannot reliably predict histologic findings of thoracic specimens. Patients with teratoma in the retroperitoneum have a high likelihood of teratoma in the thoracic specimen.

Lung Cancer Resection after Immunochemotherapy Versus Chemotherapy in Oligometastatic Nonsmall Cell Lung Cancer.

BACKGROUND: Neoadjuvant immunochemotherapy is currently being tested in pivotal trials for stage I to III nonsmall cell lung cancer (NSCLC). The impact of immunochemotherapy in patients with oligometastatic disease (OMD) remains undefined. This study aimed to compare the outcomes of radical treatment after the neoadjuvant course of immunochemotherapy versus chemotherapy. METHODS: We retrospectively analyzed patients with OMD who were treated with immunochemotherapy or chemotherapy combined with local ablation of metastases and radical primary tumor resection between 2017 and 2021. Group A included eight patients with immunochemotherapy; Group B included seven patients with chemotherapy. Descriptive statistical analysis included the characteristics of the patients, tumors, and outcomes. RESULTS: There was no difference in postoperative morbidity rates between the groups (p = 0.626). The 30-day mortality in both groups was 0%. The median overall survival for Group A was not reached, with a median follow-up time of 25 (range: 13-35) months; the median overall survival for Group B was 26 (range: 5-53) months. In Group A, all patients remained alive; in contrast, in Group B, four patients died (p = 0.026). There was no local thoracic recurrence in either group. In Group B, the recurrent disease was identified significantly more often (12.5 vs. 85.75%; p = 0.009). The rates of complete and major pathologic response were 37.5 and 0% in Group A and 42.85 and 14.25% in Group B, respectively. CONCLUSION: Despite the small patient number and short-term results, the progression-free and overall survival in patients with OMD after local therapy for metastases and primary tumor resection following a neoadjuvant course of immunochemotherapy might be promising compared with chemotherapy.

The role of residual tumor resection in the management of nonseminomatous germ cell cancer of testicular origin.

OBJECTIVE: To assess the outcome of patients with testicular nonseminomatous germ cell tumors (TNSGCT) undergoing intrathoracic residual tumor resection (RTR) after previous chemotherapy (CT) at a single institution. METHODS: The office records of all patients who underwent intrathoracic RTR for TNSGCT after CT at a single institution from January 2000 through December 2006 were reviewed. RESULTS: There were 124 consecutive patients (age 33.1 ± 8.4 years) with residual masses who underwent 189 surgical procedures. Morbidity and mortality rates were 12.7 and 0.5%, respectively. Complete resections could be achieved in 121 patients (97.6%). In the resected lung masses, necrosis was the predominant histology, (44.4 vs. 29% in mediastinal masses p = 0.018). Mature teratoma was the leading histology in the mediastinum (62.1 vs. 39.5% in lung masses, p = 0.0006). Fifty-nine out of 124 patients (47.6%) required interventions at both lungs and had discordant histological results in 20.3% (12/59) of the cases. Mean survival was 86.6 ± 2.6 months. The overall 5-year-survival and 10-year survival rates were 87 and 85%, respectively. Viable cancer, incomplete resections, age ≥ 34 years, and major pulmonary resections were associated with inferior survival in a univariate Cox proportional hazards model. In a multivariable Cox proportional hazards model, viable cancer, incomplete resections, and major pulmonary resections remained significant prognostic factors. CONCLUSIONS: In selected TNSGCT patients with residual masses, RTR can be performed safely after CT. RTR should be attempted at all sites because of possible discordant histological differentiation. Complete and parenchyma-sparing resections are associated with excellent long-term survival, which can be influenced by the surgeon.

Pulmonary Resection after Radiosurgery and Neoadjuvant Immunochemotherapy for NSCLC Patients with Synchronous Brain Metastasis-A Case Series of Three Patients.

Brain metastases are a common finding upon initial diagnosis of otherwise locally limited non-small cell lung cancer. We present a retrospective case series describing three cases of patients with symptomatic, synchronous brain metastases and resectable lung tumors. The patients received local ablative treatment of the brain metastases followed by neoadjuvant immunochemotherapy with pemetrexed, cisplatin, and pembrolizumab. Afterwards, resection of the pulmonary lesion with curative intent was performed. One patient showed progressive disease 12 months after initial diagnosis, and passed away 31 months after initial diagnosis. Two of the patients are still alive and maintain a good quality of life with a progression-free survival and overall survival of 28 and 35 months, respectively, illustrating the potential of novel combinatorial treatment approaches.

Resection of retrocrural germ cell tumor metastases: Two surgical approaches.

OBJECTIVES: The goals of retrocrural metastasectomy are complete resection with preservation of the diaphragmatic function while avoiding phrenic nerve injury and spinal cord ischemia. We describe 2 approaches for metastasectomy depending on the pattern of metastases. METHODS: Between 1999 and 2017, 44 patients underwent 50 retrocrural metastasectomies. In case of lower retrocrural, bilateral retrocrural, and or additional retroperitoneal and abdominal metastases, an abdominal approach with mobilization of the liver and the kidney followed by longitudinal incision of the diaphragmatic crus was performed. In case of upper retrocrural metastases and additional thoracic disease, a thoracic approach was performed. The Kaplan-Meier method and log-rank test were used to analyze survival and prognosticators. RESULTS: The minor morbidity, major morbidity, and mortality were 16.6%, 0%, and 0% for the abdominal approach, respectively, and 15.4%, 3.8%, and 0% for the thoracic approach. There was no phrenic nerve palsy, diaphragmatic hernia, or spinal cord ischemia. Additional retroperitoneal, mediastinal, pulmonary, or further resection was necessary in 10, 25, 9, and 6 cases, respectively. In all cases, a R0 resection was achieved. The 15-year survival rate was 95%. CONCLUSIONS: Depending on the pattern of metastases, a complete retrocrural metastasectomy with low morbidity and without mortality by thoracic or abdominal approach is possible. Both approaches preserve diaphragmatic function. Furthermore, the lateral abdominal approach provides a good view and might lead to less tension at the spinal arteries and therefore might reduce the risk of paresis. Good long-term survival is achievable. These patients should be operated on in specialized centers.