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OBJECTIVES:
A metastatic tumor of the retroperitoneum involving the region of the abdominal aorta is an uncommon entity in the vascular community. Recurrence rates of metastatic tumors decreases with time and only a few cases are documented of recurrence 10 years after initial presentation has been reported. The purpose of this case report is to describe the successful treatment of a retro-peritoneal tumor by aortic stent graft then subsequent resection in close proximity to the abdominal aorta. The placement of an abdominal endograft for resection of a tumor is rarely described in current literature.
METHODS:
A 44-year-old Caucasian male with abdominal pain was admitted with an incidental finding of a 5x3 cm left para-aortic mass, left of the renal artery extending to the aortic bifurcation. The patient has a history of metastatic testicular cancer of the lung status-post left-sided orchiectomy treated with chemotherapy and resection of right pulmonary lesion approximately 15 years prior. The Alpha-fetoprotein serum was measured at 676.0. A CT-guided biopsy was performed, the pathology revealed positive cells for pankeratin and cytokeratin 7 along with a focal positivity for AFP, compatible with metastatic disease.
Surgery was performed by lining of the aorta with a Gore-Tex excluder stent graft then subsequent laparotomy and resection of the tumor. Pathology showed the tumor demonstrated a poorly differentiated malignant neoplasm with features consistent of metastatic embryonal carcinoma. The patient completed two-cycles of adjuvant VIP chemotherapy.
RESULTS:
Two months post-operatively, Duplex ultrasound demonstrated normal position of aortic endograft, no evidence of aneurysmal disease or perigraft flow. AFPs started normalizing which appear to be a biochemically responding status post resection. Two months post-operatively, the Alpha-fetoprotein serum was measured at 38.1, 6 months at 5.6.
CONCLUSIONS:
Traditionally, metastatic tumors have been treated with systemic therapy. However, studies show long term survival after first line chemotherapy is contingent upon resection of Germ Cell tumors. Metastatic tumors with involvement of the abdominal aorta make resection difficult.
Theoretically, the use of an aortic endograft may protect the resected sections, provide avoidance of future pseudoaneurysmal disease, and decrease surgical morbidity by potential avoidance of an aortic cross-clamp along with the associated fluid shifts and visceral ischemia.
Long-term evaluation regarding the integrity of the endograft with neoadjuvant therapy and potential tumor recurrence should be addressed.