The Role of Retroperitoneal Lymphadenectomy in Clinical Stage B Testis Cancer: The Indiana University Experience (1965 to 1989)

Abstract

Between 1965 and 1989, 1,180 patients underwent retroperitoneal lymph node dissection for nonseminomatous germ cell testis cancer (638 underwent primary dissection). Of these patients, 174 were considered to have clinical stage B disease preoperatively (suspected retroperitoneal node metastases by clinical staging). Surgery revealed that 41 patients (23%) actually had pathological stage A disease (no cancerous nodes). This nonspecificity in clinical staging remains consistent despite advance in clinical staging methods during this 25-year period. Of the pathological stage B cancer patients 65% were cured by retroperitoneal lymph node dissection alone. These long-term data indicate that primary retroperitoneal lymph node dissection for low stage metastatic nonseminomatous germ cell testis cancer (pathological stage B) not only had diagnostic but also therapeutic impact. Furthermore, this cure rate with long-term followup is equivalent to that of current series of primary chemotherapy alone for stage B disease, which are still relatively early reports. This cure rate with single modality therapy (retroperitoneal lymph node dissection alone) was accomplished within an average of 4 hours and, therefore, should be more time and cost-effective than prior reports of 3 and 4 courses of primary chemotherapy. In the post-cisplatin era (1979 to 1989), 140 patients with clinical stage B disease were treated with primary retroperitoneal lymph node dissection: 32 (23%) had pathological stage A cancer and 2 of them (6%) had relapse. Both patients are currently disease-free with subsequent chemotherapy. Of the remaining 108 patients with pathological stage B disease 49 received no adjuvant chemotherapy and 59 received cisplatin-based adjuvant chemotherapy. Among the former 49 patients 18 (37%) had relapse and 2 died. No patient receiving postoperative cisplatin-based adjuvant chemotherapy had relapse. The overall survival rate in these 140 clinical stage B cancer patients was 98%. There were 3 deaths, only 1 from cancer. The addition of cisplatin-based adjuvant chemotherapy postoperatively has rendered pathological stage B nonseminomatous germ cell testis cancer entirely free of subsequent relapse. Therefore, retroperitoneal lymph node dissection as monotherapy is curative in two-thirds of the patients with stage II disease, while the remaining one-third with progression to clinical relapse can be reliably saved by chemotherapy. Future considerations in selecting therapy for clinical stage II nonseminomatous germ cell testis cancer will be risk-benefit, cost-benefit and quality of life issues. Several cooperative studies will examine these issues, involving European and United States groups.

Long–Term Experience with Laparoscopic Retroperitoneal Lymph Node Dissection in the Management of Low–Stage Testis Cancer

“…On the other hand, retroperitoneal lymphadenectomy is the only currently reliable method to identify as early as possible patients with germ cell tumors who already have pathological stage–II disease [42]. Because of the insufficiency of clinical staging alone, surveillance without prior lymph node dissection has a relapse rate of 19–40% [1, 2, 3, 4, 5, 6, 7, 18]versus 5–10% for pathologic stage–I testicular cancer after retroperitoneal lymphadenectomy [9, 10, 13, 16].…”

Canadian consensus guidelines for the management of testicular germ cell cancer

“…Primary RPLND alone has been demonstrated in high relapse rates with 30% for patients with stage IIA and 50% for patients with stage IIB disease. [82][83][84][85] Primary RPLND followed by adjuvant chemotherapy with two cycles of BEP exposes all patients to two different treatment modalities including surgery-related complications, such as retro- …”

Testicular Cancer

“…RPLND was curative as monotherapy in 67% of cases and relapse way from the retroperitoneum occurred in 33% of patients. Regarding morbidity, anejaculation rates were of the order of 1±10%; death rate was 2% [1].…”