Surgical techniques for testicular nonseminomatous germ cell tumors metastatic to the mediastinum.

Since 1980, the author and his colleagues have performed over 400 thoracic surgical procedures to remove residual mediastinal disease after cisplatin-based chemotherapy in nearly 300 patients with testicular nonseminomatous germ cell tumors [6]. Presurgical planning is individualized and may require coordination with urologic and head and neck surgeons to minimize the overall number of surgical procedures while maximizing exposure. Careful and systematic dissection can remove teratomatous residual disease from major blood vessels and intrathoracic nerves with minimal morbidity. The operative mortality rate has been low (1%), which is not unexpected in these otherwise young and healthy patients. The 10-year survival rate has been 78% from the time of diagnosis with removal of benign residual mediastinal disease pathologically consisting of either necrosis or teratoma. This success justifies an aggressive thoracic surgical approach in these cases. Commonly, multiple surgical procedures are required to remove bilateral or multiple levels of residual mediastinal disease or disease that presents during long-term follow-up. Prolonged survival seems possible following the resection of limited areas of persistent nonseminomatous germ cell tumors or nonseminomatous germ cell tumor degeneration into non-germ cell cancer within the mediastinum. Salvage surgery to remove chemotherapy-refractory mediastinal disease represents a situation in which significantly poorer long-term survival is anticipated; however, an aggressive surgical approach is justified in select patients.