Resection of late intravascular germ cell tumor recurrence under hypothermic circulatory arrest

Abstract

Objective: to describe an unusual case of late metachronous intravascular recurrence of germ cell tumor in a young patient requiring complex surgical management. Patient: The patient is a 46-year-old gentleman with complex history of germ cell tumor who had previously undergone right radical orchiectomy, chemotherapy, retroperitoneal lymph node dissection, neck dissection for recurrence, re-do retroperitoneal lymph node dissection with caval tumor thrombectomy, and renal transplantation who presented with rising alpha fetoprotein level and a PET-CT showing an avid lesion at the confluence of the common iliac veins. Surgical Procedure: A multidisciplinary surgical team was assembled including cardiac surgery given the anticipated need for cardiopulmonary bypass and circulatory arrest. A midline laparotomy with extensive lysis of adhesions was performed. The great vessels were skeletonized, and a sternotomy was performed and bypass was initiated. The patient was cooled and circulatory arrest with antegrade cerebral perfusion commenced. The intravascular mass was resected with negative surgical margins, and the common iliac vein was closed primarily. Results: Total operative time was 10 h, and estimated blood loss was 300 mL. The patient was discharged home on postoperative day 5. Final pathology revealed yolk sac tumor with negative surgical margins. He remains free of surgical complications or recurrence. Literature review demonstrates that metachronous intravascular germ cell tumor is an uncommon entity. Conclusions: Complex cases of intravascular germ cell tumor can be successfully surgically managed with an appropriate multidisciplinary team and extensive preoperative planning.

Keywords

• Testicular cancer
• Intravascular tumor
• Circulatory arrest