Causes of nonretroperitoneal residual masses

Testicular cancer most frequently metastasizes by way of the lymphatics to the retroperitoneal lymph nodes. Dissemination to more distant sites is not uncommon, however. Up to 35% of patients who have advanced testicular cancer demonstrate residual masses at more than one site after initial chemotherapy [9]. Although hematogenous metastases, particularly with choriocarcinoma, to the lung, liver, bone, or brain may occur, the most common mechanism for spread outside of the ret-roperitoneum is through contiguous lymphatics to the mediastinum. Although cisplatin-based chemotherapy often suffices for the management of patients who have metastases outside of the retro-peritoneum, consolidation surgical resection is frequently necessary. A large, multicenter, retrospective review examined the sites of residual masses after induction chemotherapy for advanced GCT [10]. Some 27%, 15%, 4%, 2%, and 0.5% of patients demonstrated residual disease in the mediastinum, lungs, neck, liver, and brain, respectively. Another study reported that approximately 10% to 20% of cases who had supradiaphragmatic metastases require at least one thoracic surgical procedure for the excision of persistent radiographic abnormalities after chemotherapy [11]. Resection of other sites (eg, liver, bone, and brain) is less common. Hahn and colleagues [12] reported that only 57 of the 2219 patients (2.5%) who underwent post-chemotherapy RPLND at the University of Indiana also had hepatic resection of residual disease.

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