Successful emergency endovascular aortic repair for intratumoral hemorrhage in extensive retroperitoneal mass of testicular origin
Tóm tắt
Metastatic germ cell cancer of the testis is characterized by favorable prognosis since effective treatment methods are available even in cases of extensive disease. Retroperitoneal masses frequently encroach major blood vessels requiring a vascular intervention usually performed in association with the post-chemotherapy retroperitoneal lymph node dissection (RPLND). Reported clinical case describes a successful pre-treatment endovascular surgery for abdominal aortic rupture allowing for full-dose systemic chemotherapy administration, and subsequent radical surgical intervention at primary tumor site as well as metastatic retroperitoneal lymph node dissection including the reconstruction of inferior caval vein. Patient presented with left-sided testicular tumor and voluminous retroperitoneal mass with vascular involvement. Soon after the patient had been admitted for the first cycle of cisplatin-based chemotherapy, computed tomographic angiography (CTA) revealed a dorsal aortic wall rupture with active extravasation and irregular pseudoaneurysmatic dilatation of the aorta below the leak area. Retroperitoneal intratumoral hemorrhage associated with the bilateral iliac venous thrombosis required an endovascular repair procedure of infrarenal abdominal aorta. Following the successful endovascular aortic repair 3 cycles of BEP (bleomycin, etoposide, cisplatin) regimen were administered with subsequent delayed left radical orchiectomy and RPLND associated with vena cava inferior (VCI) resection. Reconstruction of VCI was originally not deemed necessary as collateral blood flow appeared sufficient, however, intraoperative complications resulted in the need for unilateral VCI reconstruction, using the interposed bypass between right common iliac vein and infrarenal segment of VCI. Histopathologic examination of the attained specimen detected no vital cancer structures. The patient remains disease-free 18 months after the RPLND.
Tài liệu tham khảo
Oldenburg J, Fosså SD, Nuver J, et al. Testicular seminoma and non-seminoma: ESMO Clinical Practise Guidelines for diagnosis, treatment and follow-up. Ann Oncol. 2013. https://doi.org/10.1093/annonc/mdt304.
Donohue JP, Leviovitch I, Foster RS, et al. Integration of surgery and systemic therapy: results and principles of integration. Semin Urol Oncol. 1998;16:65–71.
Ehrlich Y, Kedar D, Zelikovski A, et al. Vena caval reconstruction during chemotherapy retroperitoneal lymph node dissection for metastatic germ cell tumor. Urology. 2009;73(442):e17–9. https://doi.org/10.1016/j.urology.2008.02.054.
Beck SD, Foster RS, Bihrle R, Koch MO, et al. Aortic replacement during post-chemotherapy retroperitoneal lymph node dissection. J Urol. 2001;165:1517–20.
Winter C, Pfister D, Busch J, et al. Residual tumor size and IGCCCG risk classification predict additional vascular procedures in patients with germ cell tumors and residual tumor resection: a multicenter analysis of the German Testicular Cancer Study Group. Eur Urol. 2012;61:403–9. https://doi.org/10.1016/j.eururo.2011.10.045.
Terry PJ, Houser EE, Rivera FJ, et al. Percutaneous aortic stent placement for life threatening aortic rupture due to metastatic germ cell tumor. J Urol. 1995;153:1631–4.
Bredael JJ, Vugrin D, Whitmore WF Jr. Autopsy findings in 154 patients with germ cell tumors of the testis. Cancer. 1982;50:548. https://doi.org/10.1002/1097-0142(19820801)50:3%3C548::aid-cncr2820500327%3E3.0.co;2-2.
Cunningham LN, Ginsberg P, Manfrey S, et al. Massive hemorrhage secondary to metastatic testicular carcinoma. J Amer Osteopath Ass. 1989;89:341–4.
Crookes PF, Cavallo AV, Ballasubramaniam GS, et al. Major gastrointestinal haemorrhage froma metastatic testicular teratoma. Aust New Zeal J Surg. 1992;62:657. https://doi.org/10.1111/j.1445-2197.1992.tb07541.x.
Ferlay J, Soerjomataram I, Ervik M et al. GLOBOCAN 2012 v1.0. Cancer Incidence and Mortality Worldwide: IARC CancerBase No.11. Lyon, France: International Agency For Research on Cancer; 2013. https://globocan.iarc.fr.
Aparicio J, Terrasa J, Durán I, et al. SEOM clinical guidelines for the management of germ cell testicular cancer (2016). Clin Transl Oncol. 2016;18:1187–96. https://doi.org/10.1007/s12094-016-1566-1.
National Comprehensive Cancer Network. Testicular Cancer (Version 2.2020) https://www.nccn.org/professionals/physician_gls/pdf/testicular_blocks.pdf
Macleod LC, Rajanahally S, Nayak JG, et al. Characterising the morbidity of postchemotherapy retroperitoneal lymph node dissection for testis cancer in a national cohort of privately insured patients. Urology. 2016;91:70–6. https://doi.org/10.1016/j.urology.2016.01.010.
Schwarzbach MHM, Hormann Y, Hinz U, et al. Clinical results of surgery for retroperitoneal sarcoma with major blood vessel involvement. J Vasc Surg. 2006;44(1):46–55. https://doi.org/10.1016/j.jvs.2006.03.001.
Roll S, Müller-Nordhorn J, Keil T, et al. Dacron vd. PTFE bypass materials in peripheral vascular surgery—systematic review and meta-analysis. BMC Surgery. 2008;8:22. https://doi.org/10.1186/1471-2482-8-22.
Jerius JT, Elmajian DA, Rimmer DM, et al. Floppy aortic graft reconstruction for germ cell tumor invasion of the infrarenal aorta. J Vasc Surg. 2003;37(4):889–91. https://doi.org/10.1067/mva.2003.156.
Bertrand MM, Carrère S, Delmond L, et al. Oncovascular compartmental resection for retroperitoneal soft tissue sarcoma with vascular involvement. J Vasc Surg. 2016;64(4):1033–41. https://doi.org/10.1016/j.jvs.2016.04.006.
Stambo G, Valentin M, Kerr TM, et al. Endovascular treatment of an acutely ruptured abdominal aorta from tumor invasion by an unresectable retroperitoneal leiomyosarcoma. Ann Vasc Surg. 2008;22(4):568–70. https://doi.org/10.1016/j.avsg.2007.11.004.
Cantwell CP, Stack J. Abdominal aortic invasion by leiomyosarcoma. Abdom Imaging. 2006;31:120–2. https://doi.org/10.1007/s00261-005-0163-5.
Karkos CD, Pepis PD, Theologou M, et al. Retroperitoneal liposarcoma masquerading as an impending rupture of inflammatory abdominal aortic aneurysm. Ann Vasc Surg. 2019;56:354.e21-354.e23. https://doi.org/10.1016/j.avsg.2018.08.103.
Hu H, Huang B, Zhao J, et al. En Bloc Resectionwith major blood vessel reconstruction for locally invasive retroperitoneal paragangliomas: a 15-year experience with literature review. World J Surg. 2017;41:997–1004. https://doi.org/10.1007/s00268-016-3846-x.
Williamson AE, Annunziata G, Cone LA, et al. Endovascular repair of a ruptured abdominal aortic and iliac artery aneurysm with an acute ilio-caval fistula secondary to lymphoma. Ann Vasc Surg. 2002;16:145–9. https://doi.org/10.1007/s10016-001-0157-x.
Tinelli G, Cappuccio S, Parente E, et al. Resectability and vascular management of retroperitoneal gynecological malignancies: a large single-institution case-series. Anticancer Res. 2017;37:6899–906. https://doi.org/10.21873/anticanres.12153.