Resection Aorta and IVC (Major Abdominal Vessels) in Germ Cell Tumour of Testis
By Dr. Praveen Kammar
A 39 year old gentleman who had testicular cancer 12 years back and had undergone removal of the affected testis followed by chemotherapy for testicular germ cell tumour. He was evaluated for pain in the abdomen. His blood levels of tumour markers AFP, bHCG and LDH were raised. CT and PET scan showed a large retroperitoneal nodal mass nest to the large vessels of the abdomen. This mass was positive for viable testicular tumour, on biopsy. He received chemotherapy.
Postchemo CT scan showed persistent 11cm mass infiltrating right kidney vessels, inferior vena cava and left common iliac vein, aortic wall, encasing right common iliac artery, right ureter (Fig 01). It was considered inoperable at two major cancer centres.
Figure 01: CT abdomen: serial sections a-c) showing the nodal mass (solid white arrow) in the paracaval area with complete invasion of IVC and right ureter and abutting the aortic wall (aorta indicated with white hollow arrow) (d) showing complete encasement of the right common iliac artery (white solid arrow) and abutment of the left common iliac artery (white hollow arrow) by the mass.
Retroperitoenal node dissection along with removal of the large nodal mass with resection and reconstruction of blood vessels.
He underwent combined resection of aorta and IVC and iliac vessels. He also needed the removal of the right kidney for complete clearance. (Fig 2 and 3) Aorta was reconstructed with Dacron graft and IVC was reconstructed with bovine graft and Dacron. Total ischemia time was 55 minutes. (Fig 04)
Intraoperative photograph showing the extent of the mass (white arrow solid arrow), starting below renal veins, covering both IVC and aorta anteriorly (left renal vein is indicated by a white hollow arrow. The small prolene knot pointed out by blue arrow indicates the divided end of the inferior mesenteric artery).
Final reconstruction: Aorta is reconstructed with Y- Dacron graft (blue arrow). Infra renal IVC was reconstructed with a combination of Dacron and bovine graft (black arrow). A jump graft (white arrow) was used to connect the left common iliac vein to bovine graft.
The left renal vein is Patient’s postoperative period was smooth and final histology showed viable mixed germ cell tumour in the excised large RP nodal mass. He is disease-free at follow up two years post-surgery.
Testicular tumours commonly spread to nodes on either side of great vessels of the abdomen, just below the kidney vessels. Sometimes they may engulf these vessels. Complete surgical removal of the nodes is the best treatment after chemotherapy.
But in some cases such as this one, surgery may require removal of major blood vessels also. With proper preparation and experienced team combined aortocaval resections can be performed safely in select patients.