Primary Retroperitoneal Lymph Node Dissection in Clinical Stage A Non‐seminomatous Germ Cell Testis Cancer Review of the Indiana University Experience 1965–1989

Abstract

The results of primary retroperitoneal lymph node dissection (RPLND) in 464 patients with clinical stage A non-seminomatous germ cell (NSGC) testis cancer treated over 25 years (1965-1989) were reviewed. The results were analysed in clinical terms and subdivided into early (1965-1978) and contemporary (1979-1989) groups in order to be comparable with series using radiotherapy or surveillance. Between 1965 and 1978 (86 clinical stage A patients) the overall relapse rate of 15% (n = 13) was similar to that of radiotherapy series but survival (97.7% after RPLND) was superior to that achieved with irradiation (87%). From 1979 to 1989, 378 clinical stage A patients had primary RPLND and 30% of them (n = 112) had cancerous nodes. The relapse rate for pathological stage A (n = 266) was 12% and 2 patients died. The relapse rate in pathological stage B patients without adjuvant chemotherapy was 34%. No relapse was seen among 48 pathological stage B patients who received post-operative adjuvant chemotherapy. The death rate was 0.8% among 378 clinical stage A RPLND patients. While not statistically significantly different from death rates reported in current surveillance series, these consistent results spanning 2 eras (before and after cisplatin) over 25 years suggest a sound basis for the surgical approach. The anatomical and medical principles in oncology, which have supported this approach, still remain cogent today. Now that nerve-sparing techniques have been developed, the only long-term morbidity of RPLND (anejaculation) has been avoided. It would seem appropriate to include nerve-sparing RPLND techniques in the management of clinical stage A disease.

The role of 18fluoro‐2‐deoxyglucose positron emission tomography in initial staging and re‐staging after chemotherapy for testicular germ cell tumours

“…Currently, staging in GCT is used to determine the extent of disease and to facilitate the choice of treatment. However, clinical stage (CS) I nonseminomatous GCTs (NSGCTs) are understaged in 30% of patients [1], despite improvements in CT technology [2]. Consequently, the optimal treatment after orchidectomy remains controversial.…”

“…Primarily, two strategies have been applied, i.e. watchful waiting with close surveillance and chemotherapy on relapse, or primary retroperitoneal lymphadenectomy (RPLND) with or with no chemotherapy [1,3]. The morbidity of a surveillance policy is low for those patients with no progression, but the frequent follow-up visits may be stressful.…”

Current Concepts in Management of Stage I NSGCT

“…Subsequent RP relapse is rare, and abdominal imaging can be restricted to one baseline CT a few months after surgery. With the introduction of nerve-sparing technique along with various modified templates, antegrade ejaculation rates of 90-100% have been reported, with significantly reduced morbidity and virtually unknown mortality [64][65][66]. It is important to be aware of slowgrowing retroperitoneal teratomas after primary chemotherapy [67].…”

Retroperitoneal lymphadenectomy by videolaparoscopic transperitoneal approach in patients with non-siinomatous testicular tumor

“…The main argument for this management is the fact that microscopic metastases can be present in approximately 30% of cases (12)(13)(14)(15)(16), with 70% being free from disease without requiring cytotoxic chemotherapy.…”

“…With the availability of effective second-line chemotherapic agents, a proper diagnosis can be fundamental for an accurate indication of rescue ChT in cases with an active malignant component (8)(9)(10)12,(14)(15)(16)(17)(18).…”