Retroperitoneal lymph node dissection with concomitant IVC thrombectomy, caval wall resection, and grafting for metastatic NSGT

Abstract

The management of a post-chemotherapy retroperitoneal mass secondary to testicular cancer can present a surgical challenge when involving adjacent organs or major vascular structures. We present the first video of a retroperitoneal lymph node dissection (RPLND) with IVC (inferior vena cava) thrombectomy, caval wall resection resulting from metastatic non-seminomatous germ cell testis (NSGCT) cancer. In this surgical video, we highlight important surgical considerations in the management of a postchemotherapy retroperitoneal mass with direct IVC wall invasion and level 2 thrombus in such a patient. A 34 year old man underwent a right inguinal orchiectomy for a mixed NSGCT (embryonal, yolk sac, and teratoma components) and elevated serum tumor markers. He underwent systemic chemotherapy (BEP regimen x 4 cycles) with subsequent near normalization of tumor markers. His post-chemotherapy imaging revealed a 6 cm residual retroperitoneal mass with a level 2 IVC tumor thrombus and suspected direct infrarenal IVC wall invasion from the mass. The patient underwent an open post-chemotherapy RPLND, IVC thrombectomy, IVC resection and grafting. The final pathology report of the retroperitoneal mass revealed teratoma with no viable germ cell tumor elements and negative surgical margins. His intra-operative and post-operative stages were unremarkable with his IVC graft remaining patent and no evidence of disease recurrence at last follow-up. We present the first surgical video of a post-chemotherapy RPLND with IVC thrombectomy, caval wall resection and grafting for metastatic NSGCT. The final pathology report of teratoma with no viable tumor highlights the local vascular invasive potential of such pathology.