Retroperitoneal lymph node dissection in testicular cancer

Update on the Management of Low-stage Seminoma

The contemporary paradigm of testicular cancer management is achieving high and durable cure rates while minimizing the burden of treatment given the potential long-term toxicities associated with radiation therapy and systemic therapies. The management of low-stage seminoma has seen significant changes in recent years. Nuances of surveillance strategies for stage I seminoma exist and continue to evolve. Emerging data show retroperitoneal lymph node dissection is a viable treatment option for selected patients with clinical stage IIA and IIB seminoma.

Post-chemotherapy Laparoscopic Retroperitoneal Lymph Node Dissection for Mixed Malignant Germ Cell Testicular Tumors

INTRODUCTION

Retroperitoneal lymph node dissection (RPLND) is performed to treat residual disease following chemotherapy for stage II and III testicular cancer. Significant morbidity can be associated with open RPLND. As such, laparoscopic techniques have been demonstrated to be safe and effective in select cases. Outcomes following post-chemotherapy laparoscopic RPLND for mixed malignant germ cell testicular tumors (MMGCT) are limited in the literature.

PATIENTS AND METHODS

We performed a retrospective chart review for patients who underwent laparoscopic RPLND at our institution for MMGCT from May 2006 to October 2016. Patient clinical data and perioperative and oncologic outcomes were recorded.

RESULTS

Twenty-three patients underwent post-chemotherapy laparoscopic RPLND. Thirty-five percent (8/23) underwent bilateral template dissection, whereas 65% (15/23) underwent a modified unilateral template dissection. Robotic assistance was utilized in 22% (5/23) of cases. Bilateral template was inferior to unilateral template RPLND in operative time, estimated blood loss, open conversion rate, length of hospital stay, and complication rate. The mean follow-up was 35.1 months and 43.3 months for the bilateral and unilateral template groups, respectively. The mean lymph node yield and recurrence rate were similar between the 2 cohorts. One recurrence of mature teratoma was noted 67 months after unilateral laparoscopic RPLND.

CONCLUSIONS

In select patients, laparoscopic RPLND for stage II and III MMGCT is safe and effective in the post-chemotherapy setting. Bilateral template laparoscopic RPLND was associated with inferior perioperative outcomes, but similar oncologic outcomes compared with unilateral template. Patients requiring bilateral template RPLND should be considered for an open approach.

Determination of risk factors for progression in patients with viable tumor at post-chemotherapy lymph node dissection due to disseminated non-seminomatous germ-cell tumors

BACKGROUND

To assess the clinical variables that effect progression in patients with viable tumor after post-chemotherapy lymph node dissection due to disseminated non-seminomatous germ-cell tumors.

METHODS

We performed a retrospective analysis of 32 patients with viable tumor after PC-RPLND, operated between 1990 and 2016. Patients were categorized into 2 groups as favorable and non-favorable (intermedia and poor) according to International Germ Cell Consensus Classification (IGCCC). Tumor size was determined as the largest dimension of retroperitoneal mass. Clinical factors and adjuvant chemotherapy were evaluated to impact on recurrence free survival (RFS) and overall survival (OS).

RESULTS

The median age of the patients and follow-up duration were 28.5 (17-51) years and 51.5 (4-253) months, respectively. 5-year RFS and OS were 57.8-66.8%, respectively. On univariate analysis, percentage of viable tumor, IGCCC risk group, primary site, second-line chemotherapy and surgical margin status were significant for RFS (p = 0.034, p = 0.002, p < 0.001, p = 0.011 and p < 0.001, respectively), while IGCCC risk group, second-line chemotherapy and surgical margin status were significant for OS (p = 0.004, p = 0.010 and p < 0.001, respectively). On multivariate analysis, second-line chemotherapy and surgical margin were independent risk factors for RFS (p = 0.016, HR 4.927 95% CI 1.34-18.02 and p < 0.001, OR 9.147 95% CI 2.61-31.98, respectively) and surgical margin status was the only predictor of OS (p = 0.038, HR 3.874 95% CI 1.07-13.69).

CONCLUSION

Retroperitoneal lymph node dissection with negative surgical margin is essential for patients with viable residual tumor after chemotherapy. Need for second-line chemotherapy shows risk of progression.

Metastatic clear cell renal cell carcinoma in isolated retroperitoneal lymph node without evidence of primary tumor in kidneys: A case report

BACKGROUND

Retroperitoneal lymph node dissection (RPLND) plays a diagnostic, therapeutic, and prognostic role in myriad urologic malignancies, including testicular carcinoma, renal cell carcinoma (RCC), and upper urinary tract urothelial carcinoma. RCC represents 2% of all cancers with approximately 25% of patients presenting with advanced disease. Clear cell RCC (CCRCC) is the most common RCC, accounting for 75%-80% of all RCC.

CASE SUMMARY

A 71-year-old man presented with a history of benign prostatic hypertrophy. He was asymptomatic without any hematuria, pain, or other urinary symptoms. A computed tomography (CT) scan of the abdomen and pelvis showed a 1.8 cm left retroperitoneal lymph node. There was no evidence of renal pathology. A core biopsy was performed of the left para-aortic lymph node. Although the primary tumor site was unknown, the morphological and immunohistochemical features were most consistent with CCRCC. A RPLND was performed which revealed a single mass 5.5 cm in greatest dimension with extensive necrosis. The retroperitoneal lymph node was most compatible with CCRCC. A nephrectomy was not conducted as a renal mass had not been detected on any prior imaging studies. The patient did not receive any type of adjuvant therapy. The patient underwent surveillance with serial CT scans with contrast of the chest, abdomen, and pelvis for the next 5 years, all of which demonstrated no recurrent or metastatic disease and no evidence of retroperitoneal adenopathy.

CONCLUSION

Our unique case emphasizes the therapeutic role of metastasectomy in metastatic CCRCC even in the absence of primary tumor in the kidneys.

Laparoscopic Retroperitoneal Lymph Node Dissection as a Safe Procedure for Postchemotherapy Residual Mass in Testicular Cancer

BACKGROUND

To evaluate the feasibility, clinical and perioperative outcomes of laparoscopic retroperitoneal lymph node dissection (L-RPLND) in the management of patients with germ cell tumors (GCT) and residual post-chemotherapy mass.

METHODS

We report our experience of 25 patients treated with L-RPLND between 2008 and 2015. All 25 patients were diagnosed with GCT by primary pathological evaluation of the specimens after orchiectomy. All patients received cisplatin-based chemotherapy. The technique consisted of L-RPLND excision of the residual mass using unilateral template dissection. We assessed perioperative data and histological findings.

RESULTS

Surgery was successfully completed in 24 (96%) patients, 1 patient required an open surgery due to intense adhesions of the mass to the inferior vena cava. Mean operation time was 213 minutes. Mean blood loss was 260 mL. Postoperative complications were upper limb osteomuscular pain in 2 patients and chylous ascites in 1 patient. Mean postoperative hospital stay was 2 days. The median residual mass diameter was 3.3 cm (range 1.1-6.6 cm). Histopathological findings were necrotic tissue in 9 patients, teratoma in 9 patients, viable tumor in 6 patients, and Castleman disease in 1 patient. The median follow-up was 30 months. Normal antegrade ejaculation was preserved in all patients.

CONCLUSIONS

Laparoscopic postchemotherapy RPLND is a feasible, safe, and highly oncologically efficient procedure, which has the benefits of minimally invasive surgery.

Post-Chemotherapy Robotic Retroperitoneal Lymph Node Dissection: Institutional Experience

PURPOSE

There is little literature on robotic retroperitoneal lymph node dissection (RRPLND) in the difficult post-chemotherapy (PC) setting. We report on the outcome of RRPLND in patients with PC-residual masses.

MATERIALS AND METHODS

Between 2011 and 2015, we performed 12 PC-RRPLND. Mean patient age was 37.8 years. Mean body mass index was 30.78. Nine (75%) patients had nonseminomatus germ cell tumor (NSGCT) and three (25%) patients had seminoma tumors. Cancer stage was III in six (50%), II-C in three (25%), II-B in two (16.7%), and II-A in one (8.03%). International Germ Cell Cancer Collaborative Group (IGCCCG) prognostic classification in the NSGCT was good in six, intermediate in two, and poor in one, and was good in the three seminoma patients.

RESULTS

The procedure was completed effectively in 11 (91.7%) patients. Mean operative time was 312 minutes. The mean estimated blood loss was 475 mL. Mean hospital stay was 3.2 days. Mean number of lymph node excised was 12. Six of the excised masses were ≥5 cm (N3), largest was 7.5 cm. Pathology showed teratoma in five (45.5%), benign/necrosis in five (45.5%), and viable germ cells in one (9%). Major complication (Clavien ≥3) occurred in one patient and minor (Clavien ≤2) in two. Antegrade ejaculation was preserved in eight patients and in one could not be assessed. At a median follow-up of 31 months, no infield or outfield relapses occurred.

CONCLUSIONS

Robotic PC-retroperitoneal lymph node dissection (RPLND) is technically feasible and with acceptable morbidity. It is associated with low blood loss and short hospital stay. More research is needed to assess the long-term outcome and to compare standard open RPLND.