Successful management of chylous ascite after removal of residual mass in non-seminomatous germ cell tumours following chemotherapy: A single-center experience and review of the literature

Abstract

Introduction

Chylous ascites is a rare but morbid condition following removal of residual mass in non-seminomatous germ cell tumours following chemotherapy.

Case presentation

We hereby present the case of a 20-year-old man who had undergone RPLND with complete surgical excision. A lesion of the Cisterna chyli complicated the operation. The post-operative course was marked by the appearance of chylous ascites. The conservative management strategy for this complication was successful, but only after a month.

Clinical discussion

Chylous ascites is a rare but morbid condition following removal of residual mass in non-seminomatous germ cell tumours following chemotherapy. Conservative management based on a high-protein diet with fat restriction and medium-chain triglyceride supplementation, and somatostatine are usually successful. Surgery should be reserved for situations that are refractory to treatment.

Conclusions

We report our successful management and, we also analysed the different management protocols using our experience and review of the literature.

Highlights

• •Since chylous ascites is a rare but morbid condition following removal of residual mass in non-seminomatous germ cell tumours following chemotherapy.
• •Conservative management based on a high-protein diet with fat restriction and medium-chain triglyceride supplementation, and somatostatine.
• •Surgery should be reserved for situations that are refractory to treatment.

1. Introduction

Modern risk-adapted systemic chemotherapy with or without postchemotherapy surgery for patients with disseminated testicular nonseminoma germ cell tumor (NSGCT) results in superb outcomes. Depending on the stage at diagnosis, 20–50 % of patients who undergo induction chemotherapy for metastatic germ cell tumor (GCT) have significant residual retroperitoneal disease. Resection is mandatory in all patients with a residual mass > 1 cm in greatest diameter at cross-sectional imaging after chemotherapy due to the significant risk of finding mature teratoma in 40–45 % of cases and viable GCT in 10–15 % of patients [1].

Chylous ascites is a rare complication reported between 0.2 % and 6.7 % in surgical procedures involving dissection adjacent to lymphatic systems [2].

The three major urological procedures identified in the literature as causing refractory chylous fluid leaks are nephrectomy, retroperitoneal lymph node dissection (RPLND) and excision of the inferior vena cava [3].

However, the complications, preventive measures and appropriate management have not been well documented in the literature. Consequently, the aim of this study is to propose an appropriate therapeutic strategy for this complication, which, although rare, should not be ignored.

2. Case presentation

After a left orchiectomy and four cycles of chemotherapy for a metastatic non-seminomatous germ cell tumor of the testicle, our patient, a 20-year-old man of African origin, presented with residual masses on the follow-up thoraco-abdominal-pelvic scan (Red arrow: Left mesenteric 61*72 cm, Inter-aorto-cava 14*18 cm, Left para-renal 15*21 cm and Right primitive Iliac 13*16 cm) (Fig. 1).

Fig. 1.

Sagital CT section showing (red arrow) residual mass in non-seminomatous germ cell tumours following chemotherapy. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)

The patient underwent RPLND with complete surgical excision. A lesion of the Cisterna chyli complicated the operation due to infiltration and encasement of the tumor (Black arrow) (Fig. 2).

Fig. 2.

Intraoperative findings of the residual mass (black arrow).

The post-operative course was marked by the appearance of chylous ascites, as evidenced by the drainage of a chylous liquid. The drain continued to produce 1 l per day for four days before stabilising at an average flow rate of 500 mL per 24 h (Fig. 3). Fearing that our patient would develop hypoprotidemia and undernutrition, we initiated conservative treatment consisting of parenteral nutrition with medium-chain triglycerides, a somatostatin infusion of 120 mg/day and strict glycaemic control.

Fig. 3.

Ascitic fluid sample after paracentesis.

The drain stopped producing after one month and the patient had no further complications.

Histologically, all resected retroperitoneal tissues were free of active residual tumor and contained 27 nodes with reactive adenitis and one node with a mature teratoma.

If the conservative strategy is adopted, remission may take several weeks, as in our patient's case. The patient had regular ultrasound scans, and a CT scan was performed after the chyle had dried up. The best imaging for diagnosis and follow-up of chylous ascites remains the abdomino-pelvic CT scan.

All in all, it took 5 weeks for the chylous fluid to disappear, and the patient's last follow-up was two weeks ago, when he recovered completely. He is in very good general condition, having regained his usual weight.

3. Discussion

The lymphatic system comprises the ascending lumbar trunks and is formed by the convergence of the common iliac lymphatic vessels. On the left, their course is left para-aortic and on the right, inter-aortic-caval, where they are joined by lymphatics from the genitourinary system. They converge at the L1-L2 vertebral bodies to constitute the Cisterna chyli. The thoracic duct begins and then crosses the aortic hiatus into the right posterior mediastinum where it bifurcates to empty into the junction between the subclavian vein and the left internal jugular vein. Any injury to the abdominal or retroperitoneal lymphatic trunks during the operation causes chylous ascites [4].

In urology, it complicates nephrectomy, excision of the inferior vena cava and retroperitoneal lymph node dissection for testicular cancer. The proportion is even higher for curage of residual masses after chemotherapy (1.2 to 21 %) [5].

The clinical diagnosis is obvious. The biological characteristics of chylous ascites are an alkaline pH, with increased triglyceride and protein levels and reduced cholesterol and glucose levels. In the event of superinfection, the culture is positive. Lymph leakage is revealed by bi-pedial lymphography, lymphoscintigraphy, CT scan or MR lymphography. The pathognomonic sign on CT is the presence of a fat-fluid level [6].

It can potentially lead to lymphopenia, hypo-proteinemia, hypo-albuminemia and loss of antithrombin III. Complications include embolisms, thrombosis, malnutrition and immunodeficiency, with an increased risk of infection [7].

In the literature, the other cases described were managed conservatively. Indeed, conservative measures are essential, consisting of a diet based on medium-chain triglycerides. If the drain produces >200 mL per day, total parenteral nutrition is indicated. The use of somatostatin or somatostatin analogues is effective, particularly in refractory cases. [8].

However, a few rare cases have required surgical revision. Surgical management is limited and consists of surgical closure of the lymphoperitoneal fistula, or embolisation using coils or biological glue. Some authors recommend the use of palliative surgical peritoneovenous bypass procedures (Denver, LeVeen) in cases of prolonged high-flow leaks [9].

Artificial intelligence could help us improve our care. But the issue of who is responsible in the event of an error raises an ethical problem. Indeed, Taher and Al highlight this notion by pointing out that, for the moment, we can't determine whose responsibility it is: the machine, the doctor, or the research group that trained, monitored and evaluated the algorithm?

4. Conclusion

Chylous ascites is a rare but morbid condition following removal of residual mass in non-seminomatous germ cell tumours following chemotherapy. We report our successful conservative management based on a high-protein diet with fat restriction and medium-chain triglyceride supplementation, and somatostatine. Surgery should be reserved for situations that are refractory to treatment.

Abbreviations

NSGCT

testicular nonseminoma germ cell tumor

RPLND

retroperitoneal lymph node dissection

CT

computed tomography

MR

Magnetic resonance

Consent

Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.

Ethical approval

Ethics approval has been obtained to proceed with the current study.

Ethical approval for this study (Ethical Committee N°05–24) was provided by the Ethical Committee.

Funding

There are no funding sources to be declared.

Author contribution

Slaoui Amine: study concept and design, data collection, data analysis and interpretation, writing the paper.

Slaoui Aziz: study concept and design, data collection, data analysis and interpretation, writing the paper.

Mouftah Babty: study design, data collection, data interpretation, writing the paper.

Fouimtizi Jaafar study design, data collection, data interpretation, writing the paper.

Koutani Abdellatif: study design, data collection, data interpretation, writing the paper.

Iben Atyya Ahmed: study design, data collection, data interpretation, writing the paper.

Declaration of competing interest

The authors declare that they have no competing interests.

Availability of data and materials

Supporting material is available if further analysis is needed.