Impact of unnecessary exploratory laparotomy on the treatment of patients with metastatic germ cell tumor.

Abstract

Patients with testicular germ cell tumors (GCTs) may undergo unnecessary diagnostic or surgical procedures when this diagnosis is not considered. In a cohort of patients who underwent exploratory laparotomy for unsuspected metastatic GCT we determined the impact of this surgery on morbidity, therapeutic delay and cancer therapy. Between 1980 and 2001, 40 patients who underwent exploratory laparotomy for unsuspected metastatic GCT were later referred to our department for management. Patient records were reviewed retrospectively. Mean patient age at exploratory laparotomy was 34 years. All patients had a midline retroperitoneal mass and 14 had disease at other sites. At the time of evaluation at our institution abnormalities on physical examination and testicular sonogram were identified in 8 (20%) and 22 (55%) patients, respectively. Elevated serum alpha-fetoprotein and/or beta-human chorionic gonadotropin were identified in 26 patients (65%). Eight patients (22%) experienced complications from exploratory surgery. The median interval from laparotomy to chemotherapy was 29 days and in 48% of patients the delay in therapy was 30 days or greater. Of patients with a delay of 30 days or greater 60% required intensive chemotherapy (multiple regimens, or high dose or salvage chemotherapy) compared to 26% with a delay of less than 30 days (p = 0.01). Exploratory laparotomy contributes to therapeutic delay in a substantial number of patients and it complicates cancer therapy. At presentation evidence to suggest GCT was present in all patients, which highlights the importance of physician awareness in making a prompt diagnosis.