睾丸非精原细胞瘤改良腹膜后淋巴结清扫术的疗效观察

Efficacy of Modified Retroperitoneal Lymph Node Dissection for Testicular Nonseminomatous Germ Cell Tumors

背景与目的:腹膜后淋巴结清扫术是睾丸非精原细胞瘤的主要治疗方法之一,对于Ⅰ/Ⅱ期肿瘤可取得较高的治愈率。但目前手术时机尚有争论,而且传统术式并发症较高。本研究主要总结改良腹膜后淋巴结清扫术治疗Ⅰ/Ⅱ期非精原细胞瘤的疗效,探讨合理的治疗策略。方法:回顾性分析2003年8月至2007年8月在中山大学肿瘤防治中心收治的31例睾丸非精原细胞瘤患者,临床分期Ⅰ期22例,ⅡA期1例,ⅡB期5例,ⅡC期3例。所有患者于睾丸癌根治术后再行改良腹膜后淋巴结清扫术,2例于清扫术前及2例于术前、术后行BEP方案化疗2～3程,11例于清扫术后行BEP/VIP方案化疗1～5程。结果:改良腹膜后淋巴结清扫术的平均手术时间为147min(120～200min),术中平均出血量为116mL(50～300mL),送病理检查的淋巴结平均15枚(3～40枚)。15例患者有腹膜后淋巴结转移,2例淋巴结呈化疗后改变。术后病理分期Ⅰ期16例,ⅡA期6例,ⅡB期6例,ⅡC期3例,无手术并发症发生。随访8～58个月,平均32个月,29例无肿瘤生存,血AFP和HCG亦无异常升高。1例术后17个月清扫区域外腹膜后肿瘤复发,予挽救化疗2程后肿瘤标志物降至正常,继续随访2个月复发灶SD。1例术后6个月出现肝肺转移,化疗6程后达CR,随访4个月无肿瘤复发。30例(96.8%)患者术后保留了正常射精功能。术前化疗组和无化疗组RPLND的平均手术时间分别为175min和143min(P=0.002),术中平均出血量分别为200mL和104mL(P<0.001)。结论:改良腹膜后淋巴结清扫术能够有效地治疗Ⅰ/Ⅱ期非精原细胞瘤,并且在规范化手术范围的同时又减少了对正常组织器官的损伤,降低了术后并发症发生。

BACKGROUND ＆ OBJECTIVE： Retroperitoneal lymph node dissection（RPLND） is one of the main modalities for nonseminomatous germ cell tumors （NSGCTs）. RPLND has achieved relatively high efficacy for stage Ⅰ/Ⅱ NSGCTs. Currently, the postoperative complication rate of conventional RPLND is relatively high. This study was to summarize therapeutic efficacy of modified RPLND for stage Ⅰ/Ⅱ NSGCTs, thus to explore the reasonable therapy strategy for those diseases. METHODS. Clinical data of 31 patients with stage Ⅰ/Ⅱ NSGCTs underwent RPLND from Aug.2003 to Aug.2007 in Sun Yat-sen University Cancer Center, were retrospectively analyzed. All cases received modified RPLND after radical orchidectomy. Four cases received two to three cycles of BEP （bleomycin,etoposide and cisplatin） chemotherapy prior to RPLND. Thirteen cases received one to five cycles of adjuvant cisplatin-based chemotherapy after primary RPLND. RESULTS, The mean operating time was 147 min （rang 120-200 min） and the mean blood loss was 116 ml （rang 50-300 mL） of modified RPLND. The mean number of dissected lymph nodes sent for pathological examination was 15 （rang 3- 40）. Retroperitoneal lymph node metastases were confirmed in 15 eases, two of which were fibrosis. According to the pathologic classification after operation, there were 16 cases at stage Ⅰ, six cases at stage IIA, six cases at stage liB, and three cases at stage ⅡC. There was no occurrence of perioperational and postoperational complications. The mean follow-up time was 33 months, ranged eight to 58 months. Twenty-nine patients achieved tumor-free survival, without elevation of blood alpha-fetal protein （AFP） or human chorionic gonadotropin （HCG）. One patient developed postoperative recurrence in the retroperitoneum 17 months after operation. After receiving two cycles of salvage therapy, his serum AFP and beta-HCG returned to normal ranges. Another patient had metastasis in the liver and lung six months after operation, but achieved complete response after six cycles of adjuvant cisplatin-based chemotherapy. Antegrade ejaculation was preserved in 96.8% of patients. The mean operative time was 175 vs. 143 rain（P=0.002）, and the blood loss was 200 vs.104 mL in the group with and without preoperative chemotherapy, respectively（P〈0.001 ）. CONCLUSIONS： Modified RPLND achieves satisfactory results for stage Ⅰ/Ⅱ NSGCTs patients. It decreases damages to normal organs as well as causes less perioperative and postoperative complications compared to conventional PRLND.