Concomitant aortocaval resection for germ cell tumour

A 39 yr old male†, known case of germ cell tumour of the right testis, presented to the department of Surgical Oncology, Saifee Hospital, Mumbai, India, on June 3, 2017, with complaints of pain abdomen. Computed tomography imaging revealed a large retroperitoneal nodal mass, involving large vessels of the abdomen and right kidney (Fig. 1A and B), which was positive on biopsy for viable testicular tumour.

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Fig. 1 (A) Computed tomography (CT) of the abdomen showing the nodal mass (white arrow) in the paracaval area with complete invasion of inferior vena cava (IVC) and right ureter and abutting the aortic wall (aorta indicated with red arrow). (B) CT abdomen showing complete encasement of the right common iliac artery (red arrow).

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Retroperitoneal node dissection with combined resection of the aorta and inferior vena cava (IVC) and iliac vessels and right nephrectomy was done (Fig. 2). Aorta was reconstructed with Dacron graft, and IVC was reconstructed with bovine graft and Dacron (Fig. 3). The patient's postoperative period was uneventful, and final histology showed viable mixed germ cell tumour. He was disease-free at a follow up of two years and four months post-surgery; computed tomographic scan showed no residual disease (Fig. 4).

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Fig. 2 Intraoperative photograph showing the extent of the mass (white arrow), starting below renal vein covering both IVC and aorta anteriorly (left renal vein - blue arrow).

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Fig. 3 Final reconstruction: Aorta and IVC were reconstructed with Y-Dacron graft (yellow arrow) and combination of Dacron and bovine graft (white arrow). Left renal vein is seen coursing over the aortic graft (blue arrow).

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Fig. 4 Postoperative CT abdomen shows no residual/recurrent disease. Grafted aorta and IVC are shown with red and blue arrows, respectively.

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Testicular tumours commonly spread to nodes on either side of the great vessels of the abdomen, just below the kidney vessels, and sometimes may encase these vessels. Complete surgical removal of the nodes is the best treatment after chemotherapy. However, in some cases, such as this one, surgery may require removal of major blood vessels also.