進行性胚細胞腫瘍に対する後腹膜リンパ節郭清術の検討

Abstract

1986年から1997年迄に名古屋大学医学部附属病院において, 15人の進行性胚細胞腫瘍患者に後腹膜リンパ節郭清術を施行した.国際胚細胞腫瘍コンセンサス分類上, poor-risk症例8例と過半数を占めた.12例でマーカー正常化後に手術が施行されたが, 3例では正常化しなかった.平均手術時間は510分, 平均出血量は3, 806gであった.手術時間, 出血量は化学療法後も残存する体軸上の腫瘤の大きさに比例した.術中合併症は15症例中5症例に生じた.腎動脈損傷2件, 腎静脈損傷1件, 尿管損傷1件, 総腸骨動脈損傷2件であった.術後合併症では, イレウスが2件, 下大静脈切除による下肢浮腫が1件, 創離開が1件に生じた.手術により完全に腫瘍が切除でき, 病理学的にも壊死又は奇形腫であった8例中6例に癌なし生存が得られた.全ての腫瘍は取り除けなかったが病理学的には壊死又は奇形腫であった4例のうち, 2例で癌なし生存が得られた

We performed retroperitoneal lymph node dissection (RPLND) on 14 patients (IIA: 1, IIB: 4, IIIA: 3, IIIB2: 2, IIIC: 4) with testicular and one with retroperitoneal germ cell tumor at the Nagoya University Hospital between 1986 and 1997. According to the international germ cell consensus classification, 4 patients were classified as "good-prognosis", three as "intermediate-prognosis" and eight as "poor-prognosis". RPLND was performed on 12 patients with the tumor marker levels normalized preoperatively and on three without the marker normalization. The mean surgical time was 510 (195-1, 125) minutes and the mean bleeding volume was 3, 806 (100-12, 598) g. The surgical time and bleeding volume were correlated with the size of the tumor in the body axis. Intraoperative complications occurred in 5 (33%) out of 15 patients: injury of renal artery (2), renal vein (1), ureter (1) and common iliac artery (2). Postoperative complications occurred in 2 patients: ileus (2) and lower extremity edema resulting from resection of the inferior vena cava (1) and would dehiscence (1). Of the 8 patients whose completely resected retroperitoneal tumors were necrosis/fibrosis or teratoma (psCR), 6 achieved survival with no evidence of disease (NED). Among 4 patients, whose tumor was not completely resected but pathologically diagnosed as necrosis/fibrosis or teratoma (pCR), NED without recurrence was achieved in 2 and also in one with resection of relapsed teratoma 2.5 years after RPLND. All three patients with cancer tissues pathologically retained in the resected tumors (sCR or psIR), consequently died of the disease. In six patients with relapse, the initial sign was elevation of the tumor marker levels, which was noted more than 30 days postoperatively in 2 patients with psCR and 7 to 15 days in 4 patients without psCR. We believe that RPLND is needed to examine the pathology and to predict the prognosis of the poor-risk patients with NSGCT. Careful dissection of vessels is needed to reduce vascular complications.