Retroperitoneal lymph node dissection for high-risk stage I and stage IIA seminoma

[Clinical stage IIA/B seminoma - to do or not to do: the role of retroperitoneal lymphadenectomy]

About 10% of patients with seminomatous testicuar germ cell tumors are diagnosed with clinical stage II/B. The current guideline recommended treatment options include systemic chemotherapy with 3 cycles PEB or radiation therapy with 30 Gy for CS IIA and 36 Gy for CS IIB. Despite a high cure rate of 90-94% and 82-90% for CS IIA and CS IIB, respectively, both options are associated with a high rate of treatment-associated long-term toxicities. A significantly increased risk for the development of secondary malignancies, cardiovascular and metabolic disease as well as an increased for treatment-associated mortality has been proven in various studies. Primary nerve sparing retroperitoneal lymph node dissection (nsRPLND) has been evaluated in 5 prospective and retrospective clinical studies and it has emerged as a valid treatment alternative. The relapse-rate after a median follow-up of 25-33 months is in the range of 11-30%, so that 70-90% of patients are cured without being subjected to chemotherapy and potential long-term toxicities. All relapsing patients have been cured with secondary salvage chemotherapy. The frequency of significant surgery-associated complications is low with 3-13%. Therapeutic success depends on the surgical experience of the various surgeons and the chosen template, so that this type of surgical interventions should only be performed in centres of excellence with dedicated surgeons. Preoperative evaluation of the new biomarker miR371 has been shown to predict the presence of metastatic disease with an accuracy of around 100% so that this marker might be used in daily routine prior to active treatment in CS IIA/B seminomas.

Primary retroperitoneal lymph node dissection for clinical stage II seminoma: A systematic review and meta-analysis of safety and oncological effectiveness

To evaluate the oncological outcomes and safety of primary retroperitoneal lymph node dissection (RPLND) in patients with clinical stage (CS) II seminomatous testicular germ cell tumor (TGCT). A literature search using PubMed, Scopus, and Cochrane Library was conducted on July 2023 to identify relevant studies according to the Preferred Reporting Items for Systematic Review and Meta Analysis (PRISMA) guidelines. The pooled recurrence rate and treatment-related complications were calculated using a random effects model. Overall 8 studies published between 1997 and 2023 including a total of 355 patients were selected for systematic review and meta-analysis with the overall median follow-up of 38 months. The overall and infield recurrence rate were 0.14 (95% CI: 0.08-0.22) and 0.04 (95% CI: 0.00-0.11), respectively. The overall pooled rate of ≥ Clavien Dindo grade III complications was 0.04 (95% CI: 0.01-0.10); there was no significant heterogeneity (I^2 = 35.10%, P = 0.19). Antegrade ejaculation was preserved with the overall pooled rate of 0.98 (95% CI: 0.95-1.00); there was no significant heterogeneity on Chi-square and I2 tests (I^2 = 0.00%, P = 0.58). Primary RPLND is a safe and effective treatment option for patients with CS II seminomatous TGCT resulting highly promising cure rates combined with low treatment-associated adverse events, at medium-term follow-up. However, owing to the lack of comparative studies to the current standard of care and the limited follow-up, individual decision must be made with the informed patient in a shared decision process together with a multidisciplinary team.

Retroperitoneal Lymph Node Dissection in Clinical Stage IIA/B Metastatic Seminoma: Results of the COlogne Trial of Retroperitoneal Lymphadenectomy In Metastatic Seminoma (COTRIMS)

BACKGROUND

Radiation therapy and systemic chemotherapy are recommended treatment options in marker-negative clinical stage (CS) IIA/B seminoma. Despite high cure rates of 82-94%, both therapeutic options are associated with significant long-term toxicities.

OBJECTIVE

To evaluate the feasibility, oncological efficacy, and treatment-associated morbidity of primary nerve-sparing retroperitoneal lymph node dissection (nsRPLND) in CS IIA/B seminoma.

DESIGN, SETTING, AND PARTICIPANTS

A prospective, single-arm, clinical phase 2 trial including CS IIA/B seminoma patients was conducted.

INTERVENTION

Primary nerve-sparing retroperitoneal lymphadenectomy.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Relapse-free and overall survival, surgery-associated complications according to the Clavien-Dindo classification, and Kaplan-Meier methods for survival calculation were assessed.

RESULTS AND LIMITATIONS

Thirty patients at a mean age of 39.1 (34-52) yr with marker-negative CS IIA and IIB seminomas were recruited. The median follow-up was 22 (8-30) mo. Nineteen (63%) and 11 (36%) patients were diagnosed with stages IIA and B, respectively, at the time of primary diagnosis. Fourteen (47%) and 16 (53%) patients were diagnosed with CS IIA and IIB, respectively, at the time of nsRPLND. Twenty-seven and three patients underwent open and robot-assisted nsRPLND, respectively. The median operating room time was 125 (115-145) min, median blood loss was <150 ml, and median time of hospitalization was 4.5 (3-9) d. Four (13%) patients experienced Clavien-Dindo grade 3a complications. Lymph node histology revealed seminoma in 25 (80%) patients; two and three patients demonstrated embryonal carcinoma and benign disease, respectively. Sixteen patients underwent a serum analysis of miR371 preoperatively, which predicted metastatic disease in 12/13 and benign histology in 3/3 patients. Three of 30 (10%) patients developed an outfield relapse 4, 6, and 9 mo postoperatively and were salvaged by systemic chemotherapy. Limitations are the low patient number and length of follow-up.

CONCLUSIONS

The nsRPLND approach results in a high cure rate at midterm follow-up and is associated with a low frequency of treatment-associated morbidities, making this approach a feasible alternative to radiation therapy or systemic chemotherapy.

PATIENT SUMMARY

The standard treatment of clinical stage IIA/B seminomas is radiation therapy or chemotherapy, which results in a significantly increased frequency of long-term toxicity and secondary neoplasms. In this trial, we demonstrate that nerve-sparing retroperitoneal lymph node dissection is a feasible therapeutic approach with low morbidity and high oncological efficacy.

A systematic review of pN0 testicular seminoma: a new clinical entity and future directions

Retroperitoneal lymph node dissection (RPLND) for testicular seminoma with enlarged retroperitoneal lymph nodes has received increased consideration and exposed a new clinical entity: pN0 disease. Enlarged, nonmetastatic retroperitoneal lymph nodes provide insight into the natural history of seminoma while offering a benchmark for improving the accuracy of staging. The purpose of this systematic review was to report the pN0 rates, describe risk factors associated with it, and discuss emerging research that may reduce its incidence. We performed a systemic review of published literature on PubMed, Embase, Web of Science, as well as oncology meeting abstracts evaluating histology of lymph nodes in patients with testicular seminoma treated primarily with retroperitoneal lymph node dissection. Studies were excluded if histology was not reported. A total of 15 publications and abstracts were included. Although study designs were heterogeneous, there was a minimal risk of bias. Overall, the reported pN0 rates were 0% to 22%. In prospective clinical trials it was 9% to 16%. The presence of pN0 was associated with preoperative smaller lymph nodes, a solitary enlarged lymph node, or negative serum miRNA-371. The incidence of pN0 seminoma is concerning as it points to a potential historical overtreatment; however, it also represents an important inflection for testicular cancer research as quantifiable improvements in clinical staging will translate to clear benefits to patients.

The role of primary retroperitoneal lymph node dissection in the treatment of stage II seminoma

PURPOSE OF REVIEW

Stage II seminoma is responsive to chemo- or radiotherapy with a progression-free survival of 87-95% at 5 years but at the cost of short- and long-term toxicity. After evidence about these long-term morbidities emerged, four surgical cohorts investigating the role of retroperitoneal lymph node dissection (RPLND) as a treatment option for stage II disease were initiated.

RECENT FINDINGS

Currently, two RPLND series have been published as a complete report, while data from other series have only been published as congress abstracts. In series without adjuvant chemotherapy, recurrence rates ranged from 13% to 30% after follow-ups of 21-32 months. In those receiving RPLND and adjuvant chemotherapy, the recurrence rate was 6% after a mean follow-up of 51 months. Across all trials, recurrent disease was treated with systemic chemotherapy (22/25), surgery (2/25), and radiotherapy (1/25). The rate of pN0 disease after RPLND varied between 4% and 19%. Postoperative complications were reported in 2-12%, while antegrade ejaculation was maintained in 88-95% of patients. Median length of stay ranged from 1 to 6 days.

SUMMARY

In men with clinical stage II seminoma, RPLND is a safe and promising treatment option. Further research is needed to determine the risk of relapse and to personalize treatment options based on patient-specific risk factors.

Treatment de-escalation for stage II seminoma

International Germ Cell Cancer Collaborative Group good-risk metastatic seminoma has cure rates of >95%. Within this risk group, patients with stage II disease exhibit the best oncological outcomes with the standard-of-care treatment strategies of radiotherapy or combination chemotherapy. However, these treatments can be associated with substantial early and late toxic effects. Therapy de-escalation aims to reduce treatment morbidity whilst preserving oncological outcomes. The evidence supporting such approaches is largely from non-randomized institutional data, and therefore this strategy is not recognized as standard of care. Current de-escalation approaches for stage II seminoma include single-agent chemotherapy, radiotherapy and surgery based on early data from clinical studies. Increased recognition of emerging data on treatment modification to reduce morbidity whilst maintaining cure rates and consideration of therapy de-escalation could improve patient survivorship outcomes.

Therapy of clinical stage IIA and IIB seminoma: a systematic review

PURPOSE

The optimal treatment for clinical stage (CS) IIA/IIB seminomas is still controversial. We evaluated current treatment options.

METHODS

A systematic review was performed. Only randomized clinical trials and comparative studies published from January 2010 until February 2021 were included. Search items included: seminoma, CS IIA, CS IIB and therapy. Outcome parameters were relapse rate (RR), relapse-free (RFS), overall and cancer-specific survival (OS, CSS). Additionally, acute and long-term side effects including secondary malignancies (SMs) were analyzed.

RESULTS

Seven comparative studies (one prospective and six retrospective) were identified with a total of 5049 patients (CS IIA: 2840, CS IIB: 2209). The applied treatment modalities were radiotherapy (RT) (n = 3049; CS IIA: 1888, CSIIB: 1006, unknown: 155) and chemotherapy (CT) or no RT (n = 2000; CS IIA: 797, CS IIB: 1074, unknown: 129). In CS IIA, RRs ranged from 0% to 4.8% for RT and 0% for CT. Concerning CS IIB RRs of 9.5%-21.1% for RT and of 0%-14.2% for CT have been reported. 5-year OS ranged from 90 to 100%. Only two studies reported on treatment-related toxicities.

CONCLUSIONS

RT and CT are the most commonly applied treatments in CS IIA/B seminoma. In CS IIA seminomas, RRs after RT and CT are similar. However, in CS IIB, CT seems to be more effective. Survival rates of CS IIA/B seminomas are excellent. Consequently, long-term toxicities and SMs are important survivorship issues. Alternative treatment approaches, e.g., retroperitoneal lymph node dissection (RPLND) or dose-reduced sequential CT/RT are currently under prospective investigation.

Clinical stage II seminoma: management options

INTRODUCTION

The management of clinical stage II seminoma has evolved with a recent emphasis on minimizing long-term morbidity while achieving oncologic cure.

METHODS

In this review we discuss the available management options for clinical stage II seminoma with an emphasis on the emerging role of surgery in this patient population.

RESULTS

Historically, treatment options available to clinical stage II seminoma patients were limited to radiotherapy and chemotherapy. Survival rates with these options are excellent; however, both are associated with significant long-term morbidities including cardiovascular, pulmonary, and neurologic toxicities. Additionally, higher rates of secondary malignancies are witnessed in this young patient population, decades after successful treatment of the primary cancer. Recently, retroperitoneal lymph node dissection has been proposed as a first-line treatment option for patients with low-volume metastatic seminoma.

CONCLUSION

The SEMS and PRIMETEST trials are two studies examining the role of primary retroperitoneal lymph node dissection in clinical stage II seminoma, and early data show significant promise.

Outcomes and expanding indications for robotic retroperitoneal lymph node dissection for testicular cancer

Treatment of testicular cancer has made significant progress in the past decades in terms of reduction of treatment-associated morbidity and preventing over-treatment. At the forefront of this progression is utilization of the da Vinci robot to perform retroperitoneal lymph node dissections (RPLNDs) via a minimally invasive approach. The robot offers multiple potential advantages such as smaller incisions, improved 3D visualization, more precise dissection, and faster convalescence, leading to its increased usage the past several years. In this chapter, we summarize the recent progress made in robotic surgery for testicular cancer and its potential in the future. Promising preliminary data has also renewed interest in defining the role of primary RPLND in patients with seminoma, potentially sparing patients of the harmful long-term radiation and cisplatin-based chemotherapy. SEMS and PRIMETEST trials are ongoing trials that will provide significant insight into this area and potentially expand the role of robotic RPLND.

Role of primary retroperitoneal lymph node dissection in stage I and low-volume metastatic germ cell tumors

PURPOSE OF REVIEW

Early-stage testicular cancers are highly curable. Following orchidectomy, management options for stage I disease include active surveillance, nerve-sparing retroperitoneal lymph node dissection (nsRPLND) and primary chemotherapy as recommended by the current guidelines. Primary RPLND has for decades played an integral part of treatment in patients with early-stage testicular germ cell tumors (TGCT), particularly in nonseminomatous germ cell tumors (NSGCT) with focus on reducing the long-term morbidity. We review the role of RPLND in stage I NSCGT as well as stage II A/B NSGCT and as seminoma.

RECENT FINDINGS

Radiation therapy and systemic chemotherapy are established treatments for seminoma; however, long-term data has demonstrated the association of such therapies with late toxicity including secondary malignancies, hearing loss, cardiovascular disease as well as metabolic syndromes. Given the well established role of RPLND in NSGCTs, clinicians have developed an interest in utilization of surgery for low-volume retroperitoneal metastatic disease. Two prospective clinical trials (SEMS and PRIMETEST) are underway to determine the role of RPLND alone in low volume metastatic seminoma.

SUMMARY

RPLND is a highly effective treatment for early-stage germ cell tumors but represents overtreatment in low-volume stage I disease where active surveillance is recommended. RPLND has shown a promising role in low-volume stage II seminomas. Two phase II clinical trials are underway to further determine the curative potential of this approach.

Retroperitoneal Lymph Node Dissection as Primary Treatment for Men With Testicular Seminoma: Utilization and Survival Analysis Using the National Cancer Data Base, 2004-2014

BACKGROUND

The role of retroperitoneal lymph node dissection (RPLND) as first-line treatment for testicular seminoma is less well defined than for testicular nonseminomatous germ-cell tumors. We describe utilization of primary RPLND in the United States and report on overall survival (OS) after surgery for these men.

PATIENTS AND METHODS

Using 2004-2014 data from the National Cancer Data Base, we identified 62,727 men with primary testicular cancer, 31,068 of whom were diagnosed as having seminoma. After excluding men with benign, non-germ cell, and nonseminomatous germ-cell tumor histologies, those who did not undergo RPLND, those where clinical stage and survival data were unavailable, and those with testicular seminoma who underwent RPLND in the postchemotherapy setting (n = 47), 365 men comprised our final cohort. Descriptive statistics were used to summarize clinical and demographic factors. The Kaplan-Meier method was used to determine OS.

RESULTS

A total of 365 men with testicular seminoma underwent primary RPLND. At a median follow-up of 4.1 years, there were 16 deaths in the entire cohort. Five-year OS was 94.2%. Subset analysis of men with stage I and IIA/B disease who underwent primary RPLND revealed 5-year OS rates of 97.3% and 92.0%, respectively (P = .035). OS did not significantly differ in patients with stage IIA versus IIB disease (91.8% vs. 92.3%, respectively, P = .907).

CONCLUSION

Although RPLND is rarely used as primary therapy in testicular seminoma, OS rates appear to be comparable to rates reported in the literature for primary chemotherapy or radiotherapy. Ongoing prospective trials will clarify the role of RPLND in the management of testicular seminoma.

Management of Residual Mass in Germ Cell Tumors After Chemotherapy

PURPOSE OF REVIEW

The purpose of this review is to educate medical oncologists on the management of patients with residual germ cell tumors and the role of surgical resection after platinum-based chemotherapy.

RECENT FINDINGS

Patients with non-seminomatous testicular cancer and residual enlarged retroperitoneal lymph nodes > 1 cm following induction chemotherapy with normal tumor markers should undergo a post-chemotherapy retroperitoneal lymph node dissection. All patients with primary mediastinal non-seminoma should undergo surgical resection of the mediastinal mass post-chemotherapy. These are complex surgeries and require expert surgeons in high-volume centers. Patients with advanced testicular seminoma who have residual masses less than 3 cm after chemotherapy can be observed without further intervention. Patients with a residual mass > 3 cm should be evaluated with PET scan after 6 weeks of chemotherapy. Residual mass with negative PET scan can be followed by surveillance while a positive PET scan requires further work up to rule out active disease.

Current controversies on the role of lymphadenectomy for testicular cancer for the journal: Urologic Oncology: Seminars and Original Investigations for the special seminars section on the role of lymphadenectomy for urologic cancers

The role of surgery in the locoregional management of many solid tumors has long been established. For testicular cancer, the incorporation of lymphadenectomy has played an important part in generating long-term survival outcomes in excess of 90% for germ cell tumor patients. In this review, we address several clinical scenarios in which lymphadenectomy at times is underutilized, and others ill advised.

Current controversies on the role of retroperitoneal lymphadenectomy for testicular cancer

Retroperitoneal lymph node dissection (RPLND) is an important component of the multimodal treatment which cures most patients diagnosed with testicular germ cell tumors. Considering the high cure rates achieved, research focus in recent years has been directed toward improving quality of life and decreasing long-term treatment related sequelae. Consequently, the role of RPLND has evolved over the past 3 decades in both low-stage and advanced testicular cancer. The use of RPLND in clinically stage I and low volume stage II disease may offer the advantages of treating retroperitoneal teratoma which is present in 15% to 20% of patients, avoiding chemotherapy and reducing the need for frequent imaging during follow-up. Similarly, ongoing studies are evaluating the safety and effectiveness of RPLND for the treatment of early stage seminoma to avoid the long-term effects of chemotherapy and radiotherapy. RPLND is traditionally used for the treatment of residual masses >1 cm after completion of chemotherapy. Its role in subcentimeter residual masses remains somewhat controversial given the fact that 25% to 30% of these patients are found to harbor either teratoma or viable nonteratomatous germ cell tumors. The presence of teratoma increases the probability of teratoma in metastatic sites. Modified unilateral templates were developed based on early mapping studies with the aim of preserving antegrade ejaculation. Recent data suggests initial mapping studies underestimated the risk of contralateral retroperitoneal metastases which may reach 32%. Furthermore, antegrade ejaculation may be preserved in >95% of patients undergoing bilateral nerve sparing primary RPLND and >80% undergoing nerve-sparing PC-RPLND, which, in our view is the more prudent oncologic approach. Recently, multiple series have demonstrated the safety and short-term efficacy of minimally invasive RPLND; however, larger studies with prolonged follow-up are required to validate the long-term oncologic efficacy of newer techniques.

Clinical Stage IIA-IIC Seminoma: Radiation Therapy versus Systemic Chemotherapy versus Retroperitoneal Lymph Node Dissection

BACKGROUND

Clinical stage II (CSII) seminoma is defined by the presence of pure seminoma accompanied by retroperitoneal lymph node metastases. In patients with bulky disease (lymph nodes > 5 cm in diameter), platinum-based chemotherapy is the widely accepted standard of care. However, the optimal choice of treatment for CSIIA and IIB is more controversial.

METHODS

We performed a PubMed search using the key words stage II seminoma, BEP (cisplatin, etoposide, and bleomycin), hockey-stick radiotherapy, dog-leg radiotherapy and retroperitoneal lymph node dissection. Most relevant publications were summarized for this review.

RESULTS

To date, no randomized trials have prospectively compared radiotherapy (RT), chemotherapy (CT) and retroperitoneal lymph node dissection (RLND) for CSII seminoma. Because of the predominantly retrospective analyses and only few prospective trials data interpretation is complex. In CSIIA with lymph nodes of < 2 cm, RT and CT seem to be equally effective, while in CSIIB, a decreased number of relapses were observed in CT-treated patients. In addition, RT seems to be associated with a higher incidence of long-term sequelae when compared with CT.

CONCLUSION

Prospective clinical trials are needed to systematically compare the different treatment modalities. De-escalation of treatment intensity without loss of efficacy is required to improve long-term outcome for this young patient population.

Retroperitoneal Lymph Node Dissection as Primary Treatment for Metastatic Seminoma

Reducing the long-term morbidity in testicular cancer survivors represents a major area of interest. External beam radiation therapy and systemic chemotherapy are established treatments for seminoma; however, they are associated with late toxicities such as cardiovascular disease, insulin resistance, and secondary malignancy. Retroperitoneal lymph node dissection (RPLND) is a standard treatment for nonseminomatous germ cell tumors (NSGCT) that has minimal long-term morbidity. Given the efficacy of RPLND in management of NSGCT, interest has developed in this surgery as a front-line treatment for seminoma with isolated lymph node metastasis to the retroperitoneum. Four retrospective studies have shown promising results when surgery is performed for seminomas with low-volume retroperitoneal metastases. To better determine if RPLND can be recommended as a primary treatment option, two prospective clinical trials (SEMS and PRIMETEST) are underway. This review will examine the literature, discuss the benefits/limitations of RPLND, and compare the methodologies of the two ongoing clinical trials.

Modern Management of Testicular Cancer

Testicular cancer is a rare urological malignancy with high cure rate. The development of highly effective systemic treatment regimens along with advances in surgical treatment of advanced disease has led to continued improvement in outcomes. Patients with testicular cancer who are treated following the treatment guideline mostly achieved high quality of life and long-term survival. However, patients who were identified as having non-guideline directed care were at significantly higher risk of relapse. In this book chapter, we introduce in depth the modern management of testicular cancer, including diagnosis, staging and risk stratification, treatment strategies of seminoma and non-seminoma germ cell tumors, follow-up protocols, and salvage treatment for disease relapse. We also review new studies and updates on medical and surgical management of advanced testicular cancer.

Retroperitoneal Lymph Node Dissection as First-Line Treatment of Node-Positive Seminoma

INTRODUCTION

The long-term morbidity associated with treating advanced seminoma can be significant. Retroperitoneal lymph node dissection (RPLND) has established oncologic efficacy in treating germ cell tumors with minimal long-term toxicity. We describe our experience with RPLND as a front-line treatment of lymph node-positive seminoma.

MATERIALS AND METHODS

We reviewed our institutional review board-approved testicular cancer database to find the patients with pure seminoma and isolated retroperitoneal lymph node disease who had undergone primary RPLND. The clinical and pathologic variables were obtained. The follow-up data were used to determine recurrence and death.

RESULTS

Four patients with a mean age of 37 years were identified. All patients had normal tumor markers and retroperitoneal lymphadenopathy measuring 1.1, 1.5, 1.8, and 5.5 cm before RPLND. Of the 4 patients, 3 had had seminoma diagnosed at orchiectomy and 1 (with a 5.5-cm retroperitoneal lymphadenopathy and a burned out primary testicular mass) had had seminoma diagnosed at RPLND after 2 nondiagnostic retroperitoneal biopsies. All patients had undergone nerve-sparing, template, extraperitoneal RPLND and were discharged home after 3 days. An average of 3 positive lymph nodes were found. Of the 4 patients, 3 had pathologic stage IIA and 1 stage IIB disease, with no patient undergoing adjuvant therapy. At a mean follow-up period of 25 months, no patient had experienced disease recurrence, and none had died. All patients maintained antegrade ejaculation, and no long-term complications had developed.

CONCLUSION

Our small series has demonstrated encouraging oncologic efficacy for RPLND as a primary treatment of retroperitoneal lymph node-positive seminoma. A multi-institutional phase II trial of RPLND for stage IIA seminoma is being developed.

[What's new in the treatment of seminomas?]

Pure testicular seminoma is a rare disease with an excellent prognosis. Its management is controversial. In stage I disease, several treatment options are considered. Those are radiation therapy alone, chemotherapy alone or active surveillance, which is becoming increasingly popular. For more advanced stages, treatment is based on chemotherapy with or without radiation therapy. In this article, we review thoroughly the existing literature and recent recommendations the various treatment options, their advantages and disadvantages in different stages of the disease.