Retroperitoneal lymphadenectomy in staging and treatment. The development of nerve-sparing techniques

Nerve-sparing technique in RPLND for testicular cancer

PURPOSE OF REVIEW

The management of testicular cancer has evolved over time with multimodal therapy. Retroperitoneal lymph node dissection (RPLND), which is a complex and potentially morbid treatment option, remains the mainstay in surgical treatment. This article reviews the surgical template, approach and anatomical considerations with regards to nerve spare in RPLND.

RECENT FINDINGS

The standard full bilateral RPLND template has evolved over time to include the area between the renal hilum, bifurcation of the common iliac vessels, and the ureters. Morbidity with regards to ejaculatory dysfunction has led to further refinements in this procedure. Advancements in anatomical understanding of the retroperitoneal structures and their relationship to the sympathetic chain and hypogastric plexus has allowed for modification of surgical templates. Further refinements in surgical nerve sparing techniques have improved functional outcomes without sacrificing oncological outcomes. Finally, extraperitoneal access to the retroperitoneum and minimally invasive platforms have been implemented to further reduce morbidity.

SUMMARY

RPLND requires strict adherence to oncological surgical principles regardless of template, approach and technique. Contemporary evidence shows that outcomes are best for advanced testis cancer patients when managed at high volume tertiary care facilities with surgical expertise and access to multidisciplinary care.

Biomarkers of disease recurrence in stage I testicular germ cell tumours

Stage I testicular cancer is a disease restricted to the testicle. After orchiectomy, patients are considered to be without disease; however, the tumour is prone to relapse in ~4-50% of patients. Current predictive markers of relapse, which are tumour size and invasion to rete testis (in seminoma) or lymphovascular invasion (in non-seminoma), have limited clinical utility and are unable to correctly predict relapse in a substantial proportion of patients. Adjuvant therapeutic strategies based on available biomarkers can lead to overtreatment of 50-85% of patients. Discovery and implementation of novel biomarkers into treatment decision making will help to reduce the burden of adjuvant treatments and improve patient selection for adjuvant therapy.

Phase 2 Single-arm Trial of Primary Retroperitoneal Lymph Node Dissection in Patients with Seminomatous Testicular Germ Cell Tumors with Clinical Stage IIA/B (PRIMETEST)

BACKGROUND

Primary retroperitoneal lymph node dissection (RPLND) for clinical stage (CS) IIA/B seminoma without adjuvant treatment is an experimental treatment to avoid radiotherapy- or chemotherapy-related toxicity from standard treatment.

OBJECTIVE

The PRIMETEST trial aimed to prospectively evaluate the oncological efficacy and surgical safety of primary RPLND.

DESIGN, SETTING, AND PARTICIPANTS

PRIMETEST is a single-arm, single-center prospective phase 2 trial. Patients with seminoma, unilateral retroperitoneal lymph node metastases <5 cm, and human chorionic gonadotropin levels <5 mU/ml were included. Patients with CS IIA/B seminoma at initial diagnosis, and recurrence under active surveillance or following adjuvant carboplatin for CS I disease were eligible.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Unilateral open or robot-assisted primary RPLND was performed. The primary endpoint of the study was progression-free survival (PFS) after 36 mo. The trial was considered positive if <30% of patients experienced a recurrence.

RESULTS AND LIMITATIONS

Between 2016 and 2021, 33 patients were accrued (nine with primary CS IIA/B, 19 recurrences during active surveillance, and five recurrences following adjuvant carboplatin). Thirteen and 20 patients had CS IIA and IIB, respectively. Open and robot-assisted RPLND procedures were performed in 14 (42%) and 19 (58%) patients, respectively. After a median follow-up of 32 mo (interquartile range 23-46), ten recurrences were detected (30%, 95% confidence interval: 16-49%); thus, the primary endpoint was not met. Infield recurrences occurred in three of ten patients. The current analysis of risk factors could not identify the predictors of recurrence. Three of 33 patients (9%) presented with pN0.

CONCLUSIONS

The PRIMETEST trial did not meet its primary endpoint. Nevertheless, PFS of 70% after a median follow-up of 32 mo suggests this approach to be of interest for highly selected patients. Selection criteria, however, need to be defined and validated in a larger prospective cohort of patients. Until then, surgery alone for the treatment of patients with CS IIA/B seminoma cannot be recommended outside of a clinical trial setting.

PATIENT SUMMARY

In this study, we investigated primary surgery as an alternative to conventional treatment (chemotherapy or radiation therapy) in patients with metastatic seminoma. The primary objective of the study, to prevent at least 30% of patients from recurrence, was not met. However, certain patients may benefit from this approach and thereby avoid chemotherapy or radiation therapy. Predictive factors need to be analyzed to better select patients for this surgery-only approach.

Nerve-Sparing Postchemotherapy Retroperitoneal Lymph Node Dissection (PC RPLND) for Nonseminomatous Germ Cell Tumour: Experience from a Tertiary Cancer Centre

Postchemotherapy RPLND remains an integral part of management of testicular tumours. Nerve-sparing techniques can minimize the ejaculatory dysfunction due to the procedure. We report our functional and oncological outcomes for nerve-sparing RPLND in postchemotherapy settings. We analysed data from all patients undergoing nerve-sparing PC RPLND from January 1990 to December 2013 at our institute. Antegrade ejaculation and fertility issues were determined by patient history. Nerve sparing was achieved in 30% of patients undergoing PC RPLND. Of the 33 patients who underwent nerve-sparing PC RPLND, 19 (57.8%) had antegrade ejaculation. The mean time to antegrade ejaculation was 6.8 months. After a median follow-up of 75.61 months, 5-year disease-free survival was 98%. Nerve-sparing RPLND can improve functional outcomes without increasing recurrence rates in post chemotherapy setting.

Testicular cancer

Testicular cancer is the most common malignancy among men between 14 and 44 years of age, and its incidence has risen over the past two decades in Western countries. Both genetic and environmental factors contribute to the development of testicular cancer, for which cryptorchidism is the most common risk factor. Progress has been made in our understanding of the disease since the initial description of carcinoma in situ of the testis in 1972 (now referred to as germ cell neoplasia in situ), which has led to improved treatment options. The combination of surgery and cisplatin-based chemotherapy has resulted in a cure rate of >90% in patients with testicular cancer, although some patients become refractory to chemotherapy or have a late relapse; an improved understanding of the molecular determinants underlying tumour sensitivity and resistance may lead to the development of novel therapies for these patients. This Primer provides an overview of the biology, epidemiology, diagnosis and current treatment guidelines for testicular cancer, with a focus on germ cell tumours. We also outline areas for future research and what to expect in the next decade for testicular cancer.

IGG* Practice Guidelines on Germ Cell Tumor in Adult Male Patients

Germ cell tumors are rare neoplasms that affect young males. Nearly 99% of patients with localized stage I disease and nearly 80% of patients with metastatic disease can be cured. Even patients who relapse following chemotherapy can achieve a long-term survival in approximately 30–40% of cases. The main objective in early stages and in good prognosis patients has changed in recent years, and it has become of major importance to reduce treatment-related morbidity without compromising the excellent long-term survival rate. In poor prognosis patients, there is a correlation between the experience of the treating institution and the long-term clinical outcome of the patients, particularly when the most sophisticated therapies are needed. So far, of utmost importance is the information from updated practice guidelines for the diagnosis and treatment of germ cell tumors. The Italian Germ cell cancer Group (IGG) has developed the following clinical recommendations, which identify the current standards in diagnosis and treatment of germ cell tumors in adult males.

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.

Ejaculatory physiology and pathophysiology: assessment and treatment in male infertility

Azoospermia is a heterogeneous condition with multiple etiologies and a variety of treatments. In this chapter we present a summary of retrograde ejaculation and anejaculation, both of which are characterized by an absence of antegrade semen propulsion through the male reproductive tract. Each of these affects fertility, but is pathophysiologically distinct disorders with differing evaluation and treatment. Retrograde ejaculation has a myriad of well-characterized causes, from pharmacologic disruption to interference of neural mechanisms by surgical intervention for a variety of diseases. Medication is the mainstay of treatment, although only a minority responds and develops antegrade ejaculation. For the men who are not responders to medical therapy, but still have fertility goals, there are a variety of sperm retrieval techniques to assist their reproductive abilities. Failure of emission is characterized by an absence of the emission phase and no antegrade or retrograde expulsion of ejaculatory products. If fertility is desired, these men must rely on assisted ejaculatory procedures, and treatment choice is guided by etiology and response. Ultimately, retrograde ejaculation and failure of emission are in a spectrum of ejaculatory disorders which impair male fertility.

The Evolution and Technique of Nerve-Sparing Retroperitoneal Lymphadenectomy

The evolution of retroperitoneal lymph node dissection technique and associated template modifications for nonseminomatous germ cell tumors have resulted in significant improvement in the long-term morbidity. Through the preservation of sympathetic nerves via exclusion from or prospective identification within the boundaries of resection, maintenance and recovery of antegrade ejaculation are achieved. Nerve-sparing strategies in early-stage disease are feasible in most patients. Postchemotherapy, select patients can be considered for nerve preservation. This article describes the anatomic and physiologic basis for, indications and technical aspects of, and functional and oncologic outcomes reported after nerve-sparing retroperitoneal lymphadenectomy in testicular cancer.

Current management of testicular cancer

Germ cell tumors (GCTs) of the testis are rare, but are the most common cancer in young men. GCTs may consist of one predominant histologic pattern or may represent a mixture of multiple histologic types. For treatment purposes, two broad categories are recognized: 1) pure seminoma and 2) others, which together are termed nonseminomatous GCTs (NSGCTs). In general, seminoma tends to be less aggressive, to be diagnosed at an earlier stage, and to spread predictably along lymphatic channels to the retroperitoneum before spreading hematogenously to the lung or other organs. Compared with NSGCTs, seminoma is exquisitely sensitive to radiation therapy and platinum-based chemotherapy. NSGCTs are usually mixed tumors and teratoma often exists at the sites of metastasis with other GCT elements; cure often requires chemotherapy to kill the chemosensitive-components and surgery to remove the teratomatous components. The main factors contributing to excellent cure rates of GCTs are careful staging at diagnosis; adequate early treatment using chemotherapeutic combinations, with or without radiotherapy and surgery; and very strict follow-up and salvage therapy. We review several clinical studies and summarize the current trends in the management of GCTs.

Postchemotherapy laparoscopic retroperitoneal lymph node dissection for low-volume, stage II, nonseminomatous germ cell tumor: first 100 patients

BACKGROUND

Retroperitoneal lymph node dissection (RPLND) is indicated after chemotherapy in case of radiologic incomplete remission or teratomatous elements in orchiectomy specimens. Open RPLND is associated with considerable morbidity, but technical difficulty of postchemotherapy laparoscopic RPLND (L-RPLND) can be significant; therefore, literature concerning pc L-RPLND is sparse.

OBJECTIVE

To evaluate feasibility and long-term oncologic outcome of postchemotherapy L-RPLND for clinical stage II disease at a single institution.

DESIGN, SETTING, AND PARTICIPANTS

Records of patients with nonseminomatous germ cell tumor who underwent postchemotherapy L-RPLND between 1993 and 2010 were retrospectively reviewed. Unilateral template resection was used until a bilateral nerve-sparing approach was introduced in 2004. Follow-up investigations were performed at 3-mo intervals for the first 3 yr, every 6 mo for the next 2 yr, and annually thereafter.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

This was a descriptive analysis.

RESULTS AND LIMITATIONS

The study cohort comprised 100 patients with stage II retroperitoneal disease (stage IIC: n=16; IIB: n=68; IIA with persisting tumor marker: n=16). Mean diameter of retroperitoneal masses before and after chemotherapy was 3.5 cm and 1.4 cm, respectively. Unilateral and bilateral templates were resected in 71 and 29 patients, respectively. Surgery was successfully completed in all but one patient, whose procedure was converted to open surgery due to bleeding. Mean operation time for unilateral and bilateral resection was 241 and 343 min, respectively. Mean blood loss was 84 ml. Postoperative complications were a large lymphocele in one patient and chylous ascites in another. Mean postoperative hospital stay was 3.9 d. L-RPLND specimens showed teratoma in 38 patients and active tumor in 2 patients. During a mean follow-up of 74 mo, one patient recurred. No recurrence was observed inside the applied surgical field. No patient died of tumor progression. After bilateral nerve-sparing postchemotherapy L-RPLND, 95.2% of patients reported antegrade ejaculation.

CONCLUSIONS

Postchemotherapy L-RPLND performed by experienced hands is feasible and associated with low morbidity and high oncologic efficacy.

[Retroperitoneal lymphadenectomy - pro laparoscopy]

The functional and oncological results of laparoscopic retroperitoneal lymphadenectomy (L-RPLND) have proven to be as efficacious as open series (O-RPLND) after 5 year follow-up. In the most recent publication series from high-volume laparoscopy centres, there was a trend towards fewer complications in L-RPLND compared to O-RPLND. Up to now only two case series of four treated patients have been reported adopting a robotic-assisted retroperitoneal lymphadenectomy for testicular cancer so that it is not yet possible to judge whether it is useful tool or not.

The developmental anatomy of the human superior hypogastric plexus: A morphometrical investigation with clinical and surgical correlations

The superior hypogastric plexus (SHP) is the part of the autonomic nervous system, which is responsible for the sympathetic innervation of pelvic organs and extrapelvic genitals in humans of both sexes. The SHP also functions as the anatomic pathway for the major part of visceral sensitive fibers originating from pelvic viscera. In this study, the morphology of the SHP was analyzed through anatomical dissections performed both in human adult and fetal cadavers. A computerized morphometrical investigation of the SHP was also performed and the resulting quantitative data statistically assessed. The comparison between fetal and adult SHP revealed that in the male group there was a developmental increase of six times (in height) and of about five times (in width); while in the female group, there was a developmental increase of 3.5 times both in height and width values. In addition, the distance from the superior border of the SHP to the bifurcation of the common iliac arteries presented a developmental increase of about six times in the male group, and about four times in the female group. We propose an original morphological classification with six types, based upon the anatomical arrangement of the nervous fibers in this autonomic plexus.

Retroperitoneal Surgery in the Treatment of Germ-Cell Tumors of the Testis: Retroperitoneal Lymph Node Dissection (RPLND)

Germ-cell tumors of the testis (GCTT) are rare, but have a high social impact. In fact they represent no more than 1% of male tumors (about 700 new cases per year in Italy), but electively occur in young patients, 20 to 40 years old, during their fully mature social and working life. More than 80% of patients are cured and return to a normal social, sexual, and working life. Improvements achieved both in diagnosis, with the use of scans (CT, MRI, US and recently PET) and of serum tumor markers alpha-fetoprotein (AFP), beta-fraction of human chorionic gonadotropin (β-HCG) and lactate dehydrogenase (LDH), and mainly in treatment, through the amelioration of radiotherapy and surgical techniques and, especially, with the introduction of Cisplatin, Etoposide and Ifosfamide in Chemotherapic regimens, have made germ-cell tumor a model of “curable disease”. Retroperitoneal lymph node dissection (RPLND) has indications in patients with clinical stage I (CS1) as well as in advanced disease, where it is integrated in the multimodality treatment. Anatomical studies, as well as a long-term experience, have gradually but consistently modified the surgical techniques of RPLND. Currently, “nerve sparing” RPLND represents a safe management of CS1 nonseminomatous germ cell testicular tumor with minimal morbidity and excellent outcomes. Nonetheless, surveillance and adjuvant chemotherapy are as effective as RPLND, but, in our opinion, associated with some discomforts for the patients. Laparoscopic retroperitoneal lymph node dissection (Lap-RPLND) is gaining popularity as a minimally invasive staging procedure for clinical stage I nonseminomatous testicular carcinoma, but its therapeutic role is still under investigation.

Primary vs. post-chemotherapy retroperitoneal lymph node dissection (RPLND) in patients with presence of teratoma at orchiectomy

OBJECTIVE

The presence of teratoma in the primary orchiectomy specimen creates controversies for subsequent management. Although predominant teratoma is less likely to metastasize, teratoma in the retroperitoneum may be less amenable to chemotherapy. In order to elucidate the issues about teratoma in the primary tumor, we reviewed differences between primary retroperitoneal lymph node dissection (P-RPLND) vs. post-chemotherapy RPLND (PC-RPLND) in patients with teratoma at orchiectomy.

MATERIALS AND METHODS

Patients who had undergone RPLND at our institution from 2001 to 2008 were identified, and clinical charts reviewed. Eighty-three patients with teratoma at orchiectomy were identified and perioperative data were obtained.

RESULTS

Of the 83 patients with teratoma at orchiectomy who underwent RPLND, 44 (53%) and 39 (47%) underwent primary and PC-RPLND, respectively. Median follow-up was 1.4 years. Of the 83 patients with primary teratoma at orchiectomy, there were 7 (8%) patients with pure teratoma and 76 (92%) patients with mixed histology. Of the patients with mixed histology, 72 (87%) patients had embryonal carcinoma and 36 (43%) had LVI. There were 19 (43%) positive lymph nodes for P-RPLND, of which 13 (30%) contained teratoma. For the PC-RPLND group, 30 (77%) of lymph nodes were positive, of which 28 (72%) contained teratoma. There were 3 (4%) recurrences overall, all of which recurred in the PC-RPLND group. There were 11 (13%) perioperative complications total. There were no deaths in either group.

CONCLUSIONS

Patients with teratoma at orchiectomy were associated with other high risk features and are at significant risk for metastatic disease. Patients with post-chemotherapy retroperitoneal findings are at significant risk for viable GCT and/or teratoma and should undergo PC-RPLND.

Defining the Optimal Treatment for Clinical Stage I Nonseminomatous Germ Cell Testicular Cancer Using Decision Analysis

Purpose

There is equipoise regarding the optimal treatment of clinical stage (CS) I nonseminomatous germ cell testicular cancer (NSGCT). Formal mechanisms that enable patients to consider cancer outcomes, treatment-related morbidity, and personal preferences are needed to facilitate decision making between retroperitoneal lymph node dissection (RPLND), primary chemotherapy, and surveillance.

Methods

Decision analysis was performed using a Markov model that incorporated likelihoods of survival, treatment-related morbidity, and utilities for seven undesired post-treatment health states to estimate the quality-adjusted survival (QAS) for each treatment option. Utilities were obtained from 24 hypothetical NSGCT patients using a visual analog (rating) scale and standard gamble.

Results

Overall, QAS associated with each treatment was high and differences in QAS were small. Surveillance was the preferred intervention for patients with a risk of relapse less than 33% and 37% using the rating scale and standard-gamble method of utility assessment, respectively. Active treatment was favored over surveillance for patients with relapse risk on surveillance greater than 33% and 37% by the rating scale (RPLND preferred) and standard-gamble methods (primary chemotherapy preferred), respectively. Substantial differences in average utilities were seen depending on the method used. By the rating scale, patients substantially devalued life in six of seven undesired health states but they were surprisingly tolerant of treatment-related morbidity using standard gamble.

Conclusion

A decision model has been developed for CS I NSGCT that estimates QAS for RPLND, primary chemotherapy, and surveillance by considering cancer outcomes, morbidity, and patient preferences. Surveillance was the preferred intervention for all except those patients at high risk for relapse.

Surgical management of low-stage nonseminomatous germ cell testicular cancer

The optimal treatment of low-stage nonseminomatous germ cell testicular cancer (NSGCT) is controversial. For clinical stage (CS) I NSGCT, retroperitoneal lymph node dissection (RPLND), two cycles of chemotherapy and surveillance are all accepted treatment options. For CS IIA-B, standard treatments include RPLND (+/- adjuvant chemotherapy) and induction chemotherapy (+/- RPLND). The long-term survival rate is >97% for CS I and 95% for CS IIA-B NSGCT, regardless of the treatment received. The risk of retroperitoneal metastasis varies by clinical stage (25-35% for CS I, 65-85% for CS IIA-B), and the presence of lymphovascular invasion and percentage of embryonal carcinoma in the primary tumour. Patients with elevated serum tumour markers (STMs) and adenopathy of >3 cm are at high risk of having occult systemic disease. Compared with chemotherapy, RPLND is associated with a considerably more favourable long-term morbidity profile and is the most effective method for controlling the retroperitoneum. Surveillance is associated with the lowest risk of long-term complications. As such, we favour surveillance for low-risk CS I, induction chemotherapy for those at high risk of systemic disease (elevated STM, adenopathy >3 cm), and RPLND for all others. Modified template dissections reduce the risk of ejaculatory dysfunction, but might increase the risk of local recurrence. Therefore, we favour a full-bilateral template dissection with nerve-sparing in patients with low-stage NSGCT. The therapeutic efficacy of laparoscopic RPLND is not proven and currently should be considered a staging procedure only. Adjuvant chemotherapy after RPLND is typically restricted to patients with pathological stage N2-3 disease.

Retroperitoneal lymph node dissection after chemotherapy

Retroperitoneal lymph node dissection after chemotherapy (PC-RPLND) plays a crucial role in managing patients with advanced germ cell tumours (GCTs). In the last few years improvements in radiographic staging, a better understanding of the role of serum tumour markers, and the introduction of cisplatin-based chemotherapy have all contributed to this surgical therapy. PC-RPLND is necessary when residual radiographic abnormalities are present after chemotherapy. The need for a PC-RPLND in the face of normal findings from computed tomography (CT) is controversial. CT criteria alone are not sufficiently reliable to distinguish viable tumour or teratoma from necrosis. No combination of variables can predict negative retroperitoneal pathology with sufficient accuracy after induction chemotherapy. Unresected teratoma or viable GCT are at least partly chemorefractory and, if untreated, will progress. So completeness of resection is an independent and consistent predictive variable of clinical outcome. In PC-RPLND surgical margins should not be compromised in an attempt to preserve ejaculation, although nerve-sparing dissections are possible in patients with marker normalization after chemotherapy and necrotic tissue in frozen-section histology. In these patients nerve-sparing techniques and the reduction of surgical field to the left- or right-sided template are applicable to preserve antegrade ejaculation and consecutive fertility. The size and location of residual masses coupled with the retroperitoneal desmoplastic reaction make PC-RPLND a technically demanding procedure that should be performed by experienced surgeons in dedicated referral centres.

Advances made in the treatment of testicular cancer in the U.S. Military: 1946 to the present

Testicular cancer is presently one of the most curable solid tumors, and thanks to diagnostic, surgical, and medical advances over the last several decades, the treatment of this tumor serves as a paradigm for multimodal treatment of solid malignancies. Due to testicular cancer's predilection for younger patients, many of the seminal improvements and discoveries were made possible as a result of initial investigatory groundwork laid by military physicians treating servicemen. This article reviews historical contributions of the United States Military Medical Departments in the arena of testicular cancer treatment in the post-World War II era.

Morbidity of open retroperitoneal lymph node dissection for testicular cancer: contemporary perioperative data

OBJECTIVE

To review differences between primary retroperitoneal lymph node dissection (P-RPLND) and RPLND after chemotherapy (PC-RPLND) in a contemporary series of patients with testicular cancer, to validate the proposed low morbidity.

PATIENTS AND METHODS

Patients who had undergone RPLND at our institution in 2001-2008 were identified and their clinical charts reviewed; in all, 190 were identified and perioperative data obtained.

RESULTS

Of the 190 patients who had RPLND, 98 (52%) and 92 (48%) had P- and PC-RPLND, respectively. Histology of the orchidectomy specimen consisted of embryonal carcinoma in 146 (76%) patients, also including lymphovascular invasion in 83 (44%). The mean (range) operative duration was 206 (110-475) min and the mean blood loss was 294 (50-7000) mL. The median hospital stay was 4 days. Mean blood loss, operative duration and hospital stay were significantly less for the P-RPLND than for PC-RPLND groups (P < 0.05). There were 18 (9%) perioperative complications in all. There were no deaths in either group.

CONCLUSIONS

The short-term morbidity of open RPLND is acceptable, and open RPLND is safe and effective at select tertiary centres. When compared with historical data, the present contemporary series shows that the operative duration, blood loss and hospital stay have improved, with few complications. These contemporary data should be considered when comparing laparoscopic with open RPLND.

Retroperitoneal lymph nodes in transitional cell carcinoma of the kidney and ureter

The incidence of transitional cell carcinoma of the kidney and ureter is low and for that reason limited data exists regarding the appropriate management of regional retroperitoneal lymph nodes. Lymph node metastases have consistently been associated with an adverse prognosis. However, five-year cancer-specific survival following nephroureterectomy and lymphadenectomy for patients with lymph node involvement ranges from 0–39%, suggesting a therapeutic benefit. This review covers the primary tumor characteristics associated with lymph node involvement, imaging of the lymph nodes, as well as the rationale, role, patient selection, suggested anatomic templates, and technical considerations for lymphadenectomy.

Current management of stage I testicular non-seminomatous germ cell tumours

Testicular germ cell tumors represent the most common malignancies in young males between the ages of 15 and 35; 50% of those with non-seminomatous germ cell tumors (NSGCT) have clinical stage I at diagnosis. Predictors for relapse include lymphovascular invasion, percentage of embryonal-cell carcinoma component, absence of yolk-sack histology and MIB1 proliferation rate. Therapeutic options following orchidectomy in stage I NSGCT comprise nerve-sparing retroperitoneal lymph node dissection (RPLND), surveillance or adjuvant cisplatin-based chemotherapy. Using a risk adapted approach, in about 50% of patients with clinical stage I NSGCT surveillance is favored in patients with good compliance. Adjuvant chemotherapy is recommended for patients at high risk for developing metastatic disease. Non-seminomatous germ cell testicular cancer is a curable neoplasia. All available treatment modalities produce excellent results, with a long-term survival of almost 100%. Consequently, therapy-induced toxicity is an important concern in the management of these patients. An individually tailored approach that takes into account the prognostic factor profile, as well as the patients' preferences and their ability to comply with treatment, is the key for the successful management of stage I testicular cancer.

Laparoscopic retroperitoneal lymph node dissection: does it still have a role in the management of clinical stage I nonseminomatous testis cancer? A European perspective

CONTEXT

Laparoscopic retroperitoneal lymph node dissection (L-RPLND) is not recommended as standard tool in European Association of Urology (EAU) guidelines.

OBJECTIVE

To update the role of L-RPLND in patients with clinical stage I nonseminomatous germ cell tumour (NSGCT) compared to open retroperitoneal lymph node dissection (O-RPLND).

EVIDENCE ACQUISITION

A systematic literature search from 1992 to 2008 was performed in Medline, EMBASE, and Cochrane. The largest series from each group was considered. Comparative analysis was based on raw data of series published in 2000 and later.

EVIDENCE SYNTHESIS

Results of >800 patients treated by L-RPLND reported in 34 articles were analyzed. Lymph node dissection (LND) was based on modified templates, removing an average of 16 (5-36) lymph nodes. At experienced centres, complication rates were 15.6% (9.4-25.7), including 2% (0-5) retrograde ejaculation and 1.7% (0-6) reintervention. Operating room times are longer compared to O-RPLND (204 vs 186min). Five publications with a follow-up of 63 (36-89) mo include 557 patients. One hundred twenty-six of 140 (90%) patients with positive nodes (25%, range: 17-38) received adjuvant chemotherapy, resulting in a local relapse rate of 1.4% (0.7-2.3) with no in-field recurrence; rate of distant relapses was 3.3% (1.8-4.6), including one port-site metastasis; and rate of biochemical failure was 0.9% (0.7-2.3). Two of 14 patients with positive nodes (pN1) who did not receive adjuvant chemotherapy relapsed, both 8 mo after surgery, and were salvaged by chemotherapy. Compared with O-RPLND, there was no difference in relapse rates, percentage of patients receiving chemotherapy (29% vs 31%), chemotherapy (CTx) cycles per cohort (0.6), rate of salvage surgery (1.2% vs 1.5%), and patients with no evidence of disease (NED; 100% vs 99.7%).

CONCLUSIONS

L-RPLND offers similar staging accuracy and long-term outcome to O-RPLND. In a late series of experienced L-RPLND centres, there was a trend towards fewer complications. L-RPLND represents a valuable tool for experienced laparoscopic surgeons. Further studies must focus on the curative potential of the procedure in pathologic stage IIA.

Nonrandomized comparison of primary chemotherapy and retroperitoneal lymph node dissection for clinical stage IIA and IIB nonseminomatous germ cell testicular cancer

PURPOSE Patients with clinical stage (CS) IIA and IIB nonseminomatous germ cell tumor (NSGCT) with adenopathy more than 2 cm, multiple masses, elevated serum tumor markers, or disease outside the primary landing zone have increasingly been recommended to receive primary chemotherapy over time at our institution. The impact of these selection factors on the outcome of patients managed primarily by retroperitoneal lymph node dissection (RPLND) or chemotherapy was examined. PATIENTS AND METHODS Between 1989 and 2002, 252 patients with CS IIA and IIB NSGCT were referred to our institution for initial management, of whom 136 underwent RPLND and 116 received chemotherapy and postchemotherapy RPLND. Patient information was obtained from a prospective RPLND database. Results Proportionately more patients received chemotherapy over time (22% in 1989 to 1993 v 68% in 1999 to 2002), and the relapse-free survival (RFS) subsequently improved from 84% (1989 to 1998) to 98% (1999 to 2002; P = .004) without increasing the proportion who received any chemotherapy (70% v 79%; P = .16). By increasingly selecting patients with adverse features for primary chemotherapy, the RFS after RPLND improved from 78% to 100% (P = .019), but rates of pathologic stage II and retroperitoneal teratoma were unaffected. Retroperitoneal histology and RFS did not change over time for chemotherapy patients. Primary chemotherapy was associated with improved RFS compared with RPLND (98% v 79%; P < .001), but disease-specific survival did not differ significantly (100% v 98%; P = .3). CONCLUSION Patient selection factors have significantly improved the outcome of patients with CS IIA and IIB NSGCT without substantially increasing the proportion of patients exposed to chemotherapy.

A comprehensive systematic review of testicular germ cell tumor surveillance

BACKGROUND

Testicular cancer is the most common malignancy in men aged 15-34, and its incidence has been increasing over the past half-century. Survival for stage I testis cancer approaches 100% regardless of management strategy which is often dictated by other factors such as perceived morbidity. Advances in treatment have attempted to decrease morbidity and surveillance is thought to achieve this goal.

METHODS

An English language literature search of MEDLINE from 1966 to December 2005 and CINAHL from 1982 to December 2005 was conducted using a broad search strategy. Comparative and descriptive original articles on outcomes of seminoma or NSGCT surveillance would be deemed eligible and review articles containing no original data were omitted. One hundred and thirty-eight articles were selected for formal review, during which a database was compiled that documented the first author, publication year, tumor histologic type, study purpose or topic(s), methodology, sample size, median follow-up, and relevant results.

RESULTS

Most evidence for the efficacy of surveillance is from descriptive series or non-experimental comparative studies. Relapse occurs in approximately 28% and 17% of surveillance patients in NSGCT and seminoma, respectively, and cause-specific survival is approximately 98% and 100%, respectively. Compliance with surveillance ranges from poor to adequate, however there is no evidence that compliance impacts clinical outcome. Cost analyses have yielded inconsistent results when comparing treatment modalities. There is scant literature on quality of life and psychosocial issues and results are inconsistent. Active surveillance appears to be appropriate and perhaps optimal first line management of clinical stage I seminoma and non-seminomatous germ cell tumors. Further quantitative and qualitative research is warranted to deepen understanding of these issues that may impact treatment decision-making.

The management of stage I nonseminomatous testicular germ cell tumors

Testicular germ cell tumors represent the most common malignancies in young males; 70% of patients with seminomas and 50% of those with nonseminomatous germ cell tumors (NSGCT) have clinical stage I at diagnosis. Lymphovascular invasion, embryonal-cell carcinoma component, absence of yolk sac histology and MIB1 proliferation rate represent predictors of micrometastatic diseasein stage I NSGCT. Therapeutic options following orchiectomy in patients with stage I NSGCT comprise nerve-sparing retroperitoneal lymph node dissection, surveillance or adjuvant cisplatin-based chemotherapy. All available treatment modalities produce excellent results, with a long-term survival of almost 100%. Consequently, therapy-induced toxicity is an important concern in the management of these patients. An individually tailored approach that takes into account the prognostic factor profile as well as the patient's preferences and their ability to comply with each one of the modalities is the key to the management of stage I testicular cancer.

Role of post-chemotherapy surgery in germ cell tumors

Surgery after systemic chemotherapy for advanced testicular cancer has maintained its role in staging and therapeutic management. The clinical outcome is strongly influenced by patient selection and extent of extirpative surgery. Although extensive predictive modeling has attempted to define appropriate post-chemotherapy surgical candidates based on various clinical and pathologic parameters, the accuracy of these models remains controversial. Complete removal of all post-chemotherapy residual masses in nonseminomatous germ cell tumors remains the standard of care and allows for improved prognostication of the long-term oncologic and functional outcome.

Nerve-sparing retroperitoneal lymphadenectomy

Surgery for retroperitoneal nodal metastases of testicular germ-cell tumors has evolved considerably since its inception. Minimizing injury to sympathetic nerves has involved their exclusion from resection boundaries and/or "nerve sparing," by identifying and preserving nerves within the resection field. These measures improve long-term procedure-related morbidity with equivalent rates of cancer control. We believe that nerve-sparing techniques are the standard of care and enforce good principles of surgery by demanding attention to anatomy and exposure. Experience with this procedure, knowledge of retroperitoneal anatomy, and thoughtful clinical and surgical decision making are imperative to achieving acceptable results. It behooves urologic oncologists to offer patients maximal therapeutic benefit combined with minimal morbidity and that retroperitoneal lymphadenectomy should be nerve sparing by definition.

Management of Clinical Stage I Nonseminomatous Germ Cell Testicular Cancer

The optimal management of patients who have clinical stage I nonseminomatous germ cell tumors remains controversial. Surveillance, retroperitoneal lymph node dissection (RPLND), and chemotherapy with two cycles of bleomycin-etoposide-cisplatin are established treatment options and all are associated with long-term cancer control rates of 97% or greater. Studies have consistently identified the presence of lymphovascular invasion and a predominant component of embryonal carcinoma in the primary tumor as risk factors for occult metastatic disease in these patients. Patients who do not have these risk factors are optimally managed by active surveillance given the low risk for relapse. For patients at high risk for relapse and who are not candidates for surveillance, we believe the evidence supports RPLND over primary chemotherapy.

Retroperitoneal lymph node dissection in testicular cancer

With long-term survival in excess of 90% across all stages, testicular cancer has come to represent the model for successful multidisciplinary cancer care. Retroperitoneal lymph node dissection (RPLND) remains an integral component of testis cancer management strategies for both early- and advanced-stage disease. Commensurate with improvements made in clinical staging and in our understanding of the natural history of testis cancer, lymphatic spread, and neuroanatomy, considerable modifications in the technique and template of RPLND have taken place. The morbidity of primary RPLND and postchemotherapy RPLND is low when performed by experienced surgeons. This article reviews the evolution, role, and technique of RPLND in contemporary practice.

Postchemotherapy laparoscopic retroperitoneal lymph node dissection: evaluation of complications

OBJECTIVES

Initial publications on postchemotherapy laparoscopic retroperitoneal lymph node dissection (LRPLND) have described significant intraoperative and postoperative morbidities. This report reviewed the complication rate with additional experience.

METHODS

A retrospective review of the medical records of 16 consecutive patients who underwent postchemotherapy LRPLND by a single surgeon from September 1996 to September 2005 was performed. The evaluation included tumor type, clinical stage, pathologic stage, and intraoperative and postoperative complications.

RESULTS

Postchemotherapy LRPLND was successfully performed in 14 (87.5%) of 16 patients. Seven patients (43.8%) developed complications and 2 (12.5%) required open conversion. The most complications occurred during the postoperative period and were classified as minor. Of the total patient population, 25% had minor postoperative complications. The median hospital stay was 2 days. No patient who underwent the procedure died. All intraoperative complications were vascular injuries and occurred during the first half of the series (1996 to 2000). In the second half of the series (2000 to 2005), no complications during the operative period and no vascular or major complications occurred. No retroperitoneal recurrence was noted during a mean follow-up of 32.7 months (range 5 to 108). One patient developed distant recurrence and underwent successful salvage chemotherapy.

CONCLUSIONS

Postchemotherapy LRPLND remains a challenging, but feasible, operation. With greater experience, the incidence of complications and morbidity can be reduced.

Management of patients with low-stage nonseminomatous germ cell testicular cancer

Management options for patients with clinical stage (CS) I nonseminomatous germ cell testicular cancer (NSGCT) include surveillance, retroperitoneal lymph node dissection (RPLND), or two cycles of bleomycin-etoposide-cisplatin (BEP x 2) chemotherapy. The optimal management of these patients is controversial, as cure rates of 97% or greater are reported with each of these treatment modalities. Patients without evidence of lymphovascular invasion, a predominant component of embryonal carcinoma, or advanced pathologic (p) T stage (pT 2 or greater) are at low risk for occult metastases and are optimal candidates for surveillance. Compliance with diagnostic testing and imaging is essential for a successful surveillance strategy to detect and treat metastases at an early stage. For patients who are not candidates for surveillance, RPLND offers several advantages over chemotherapy. RPLND alone is curative in 50% to 80% of CS I patients with pathologic stage (PS) II, and an estimated 75% of CS I patients avoid chemotherapy (as adjuvant therapy or for treatment of relapse). Virtually all patients are cured following two cycles of adjuvant chemotherapy for PS II disease, which is reserved for patients with high-volume (PN2-3) retroperitoneal disease. The poor outcome of patients with late retroperitoneal recurrence from unresected, chemorefractory germ cell testicular cancer indicates that RPLND is a vital component to the long-term cure of patients with NSGCT. Approximately 20% to 30% of patients with PS II disease have retroperitoneal teratoma (which is chemoresistant), and an estimated 5% of PS II patients have chemoresistant viable cancer following BEP x 2 as primary therapy. When RPLND is omitted, these patients are at risk for late recurrence with potentially lethal consequences. Patients who relapse after RPLND are "chemotherapy-naïve" and cured in virtually all cases with good-risk chemotherapy regimens. When nerve-sparing techniques are employed to preserve ejaculation, RPLND is also associated with a more favorable long-term toxicity profile compared with chemotherapy. In the absence of conclusive evidence from a randomized trial, we believe RPLND is the treatment of choice for patients with CS I NSGCT who are not candidates for surveillance, as it offers the greatest likelihood of long-term cure with considerably less morbidity than primary chemotherapy.

Retroperitoneal lymph node dissection in patients with low stage testicular cancer with embryonal carcinoma predominance and/or lymphovascular invasion

PURPOSE

The outcome after primary retroperitoneal lymph node dissection (RPLND) was analyzed in patients with clinical stage I-IIA nonseminomatous germ cell testicular cancer with embryonal carcinoma predominance (ECP) or lymphovascular invasion (LVI).

MATERIALS AND METHODS

Between 1989 and 2002, 267 patients with clinical stage I-IIA nonseminomatous germ cell testicular cancer, and ECP and/or LVI underwent RPLND. Patient information was obtained from a prospective database. Median followup was 53 months.

RESULTS

Overall 42% of patients had pathological stage (PS) II disease, of whom 54% had low volume (PN1) disease and 16% had retroperitoneal teratoma. The 5-year progression-free probability was 90% overall, 90% for PS I and 86% for PN1. All patients with relapse were continuously free of disease following standard chemotherapy with or without resection of residual masses and the 10-year actuarial overall survival was 100%. When adjuvant chemotherapy was restricted to patients with PN2 disease, the estimated 5-year relapse rate was 9% and an estimated 72% of patients avoided chemotherapy.

CONCLUSIONS

The low risk of systemic relapse in patients with PS I and PN1 after RPLND alone combined with the 16% incidence of retroperitoneal teratoma and the favorable morbidity profile supports RPLND over primary chemotherapy for the treatment of patients with low stage disease with ECP and/or LVI who are not candidates for surveillance. An estimated 72% of patients are spared the potential toxicity of chemotherapy if adjuvant therapy is restricted to patients with PN2. After primary RPLND and selective adjuvant chemotherapy late recurrence is distinctly uncommon and long-term cancer control is anticipated in essentially all patients.

Juvenile cancer: improving care for adolescents and young adults within the frame of medical oncology

Despite unique tumour epidemiology, a higher cancer incidence and modest survival improvement compared to paediatric patients, adolescents and young adults aged 15-30 have not been considered as a separate, "special" group of patients in the frame of medical oncology. In an effort to emphasise this need, we review the particular characteristics of diagnosed tumours, a aetiologic associations, nosologic classification, management, outcome and late toxic effects. Adolescents and young adults are in need of specialised care for intensive treatment of curable malignancies, skilled nursing care, interaction with peers, family and physicians as well as continuous psychosocial support. Enrollment in clinical research trials and close follow-up via the development of a cooperative infrastructure are imperative for the optimisation of management and avoidance of late effects. Similar to geriatric and paediatric oncology, we call for the intensification of treatment, support and research multidisciplinary efforts in order to better fulfil the pressing demands of this patient group.

Retroperitoneal lymph node dissection for nonseminomatous germ cell testicular cancer: impact of patient selection factors on outcome

PURPOSE

To investigate the impact of patient selection criteria on the outcome of patients with nonseminomatous germ cell testicular cancer (NSGCT) treated by primary retroperitoneal lymph node dissection (RPLND). Since 1999, our criteria have excluded patients with persistent postorchiectomy elevation of serum tumor markers (STM) or clinical stage (CS) IIB disease from RPLND.

PATIENTS AND METHODS

Between 1989 and 2002, 453 patients underwent primary RPLND at our institution for CS I to IIB NSGCT. Patient information was obtained from a prospective database. Retroperitoneal pathology and relapse rates were compared for patients treated before and after application of the current selection criteria in 1999.

RESULTS

By excluding patients with elevated STM or CS IIB disease after 1999, the proportion of pathologic stage II patients with low-volume (pN1) retroperitoneal disease increased significantly (40% before 1999 v 64% after 1999; P = .01), without significantly affecting the rate of retroperitoneal teratoma (21% v 22%, respectively; P = .89) or pathologic stage I disease (56% v 67%, respectively; P = .06). For patients who did not receive adjuvant chemotherapy, the 4-year progression-free probability improved significantly from 83% before 1999 (95% CI, 79% to 88%) to 96% after 1999 (95% CI, 91% to 100%; P = .005). Elevated postorchiectomy STM (P < .0001), clinical stage (P = .0002), and pre-1999 RPLND (P = .05) were independent pretreatment predictors of progression.

CONCLUSION

Excluding patients with CS IIB disease or elevated postorchiectomy STM from primary RPLND has had a favorable impact on the extent of retroperitoneal disease and has significantly reduced the risk of relapse after RPLND. For patients with normal STM and CS I to IIA disease, the low rate of systemic progression and 22% incidence of retroperitoneal teratoma supports RPLND as the preferred primary intervention.

Retroperitoneal lymph node dissection in the treatment of low-stage nonseminomatous germ cell tumors of the testicle: An update

Nonseminomatous germ cell tumors (NSGCT) of the testicle are highly treatable and curable. The evolution of cancer control for this disease has shown an effective integration of medical and surgical approaches over the last 3 decades. Current emphasis in the therapy of NSGCT focuses on minimizing treatment-related morbidity while maintaining consistently high cure rates as previously seen. Retroperitoneal lymph node dissection (RPLND) in experienced hands is a critical component of the treatment armamentarium in this disease. RPLND is an accurate staging tool providing important information to determine the need for chemotherapy. When performed properly, RPLND eliminates the retroperitoneum as a site for relapse, which in turn provides emotional and psychological relief to the patient, and simplifies the follow-up protocol. RPLND alone can also provide high cure rates in patients with low clinical stage disease and high risk factors, such as lymphovascular invasion or predominance of embryonal histology in the primary tumor. Teratoma is chemoresistant and, when present in the primary tumor of patients with low stage, may be best treated with primary RPLND. Primary chemotherapy in the treatment of low stage NSGCT deserves continual investigation as long-term toxicities become more apparent. Observation is an option for the highly motivated patient but requires a rigorous follow-up schedule to avoid relapse. Laparoscopic RPLND is a viable staging tool; however, oncologic control of the retroperitoneum has not been reliably determined.

Complications of laparoscopic urologic surgery

Laparoscopic techniques performed in the urologic setting have received great attention in the past decade. With the development of improved laparoscopic instrumentation, approaches to gonadal, renal, prostate, and bladder diseases have been successfully performed. A discussion of urologic laparoscopy (UL) with particular attention to potential complications and limitations is presented. Awareness of these evolving technologies remains critical to all surgeons with an interest in laparoscopy.

Retroperitoneal lymph node dissection in the treatment of low-stage nonseminomatous germ cell tumors of the testicle

Nonseminomatous germ cell tumors of the testicle are highly treatable and curable. The evolution of cancer control for this disease has demonstrated an effective integration of medical and surgical approaches over the last 30 years. Current emphasis in the therapy of nonseminomatous germ cell tumors focuses on minimizing treatment-related morbidity while maintaining consistently high cure rates. Retroperitoneal lymph node dissection in experienced hands is a critical component of the treatment armamentarium in this disease. Retroperitoneal lymph node dissection is an accurate staging tool that provides important information in determining the need for chemotherapy. When performed properly, retroperitoneal lymph node dissection eliminates the retroperitoneum as a site for relapse, which in turn provides emotional and psychological relief to the patient and simplifies the follow-up protocol. Retroperitoneal lymph node dissection alone can also provide high cure rates in patients with clinical low-stage disease and high-risk factors such as lymphovascular invasion or predominance of embryonal histology in the primary tumor. Teratoma is known to be chemoresistant and, when present in the primary tumor of low-stage patients, may be best treated with primary retroperitoneal lymph node dissection. Primary chemotherapy in the treatment of low-stage nonseminomatous germ cell tumors deserves continual investigation as long-term toxicities become more apparent. Observation is an option for the highly motivated patient, but requires a rigorous follow-up schedule to avoid relapse. Laparoscopic retroperitoneal lymph node dissection is a viable staging tool, however, oncologic control of the retroperitoneum has not been reliably determined.

Germ cell tumours of the testis

Cancer of the testis is a relatively rare disease, accounting for about 1% of all cancers in men. Cryptorchidism is the only confirmed risk factor for testicular germ cell tumour. The majority of GCT are clinically detectable at initial presentation. Any nodular, hard, or fixed area discovered in the testis, must be considered neoplastic until proved otherwise. The appropriate surgical procedure to make the diagnosis is a radical orchidectomy through an inguinal incision. Many GCT produce tumoural markers (AFP, HCG, LDH), who are useful in the diagnosis and staging of disease; to monitor the therapeutic response and to detect tumour recurrence. In 1997 a prognostic factor-based classification for the metastatic germ cell tumours was developed by the IGCCCG: good, intermediate and poor prognosis, with 5-year survival of 91, 79 and 48%, respectively. GCT of the testis is a highly table, often curable, cancer. Germ cell testicular cancers are divided into seminoma and non-seminoma types for treatment planning because seminomatous testicular cancers are more sensitive to radiotherapy. Seminoma (all stages combined) has a cure rate of greater than 90%. For patients with low-stage disease, the cure approaches 100%. For patients with non-seminoma tumours, the cure rate is >95% in stages I and II; it is approximately 70% with standard chemotherapy and resection of residual disease, if necessary, in stages III and IV. Minimum guidelines for clinical, biochemical, and radiological follow-up have been reported by ESMO in 2001.

The role of retroperitoneal lymph node dissection in the management of testicular cancer

Despite continued refinement in terms of technique and the integration of retroperitoneal lymph node dissection (RPLND) in the management of patients with testicular cancer, RPLND remains an essential component in the ultimate cure of these patients. The failure to eradicate all disease in the retroperitoneum exposes patients to the risk of late relapse events with potentially lethal consequences. For patients with low-stage nonseminomatous germ cell tumor (NSGCT), primary RPLND is an important staging tool to define subsequent treatment requirements, simplify the follow-up of patients by obviating the need for routine abdominal imaging, and limit the exposure of patients to the long-term toxicity of chemotherapy. RPLND alone is curative in up to 90% of patients with low-volume retroperitoneal disease. In the post-chemotherapy setting, the inability to reliably exclude the presence of teratoma or viable germ cell cancer in the retroperitoneum mandates that post-chemotherapy RPLND be performed for all NSGCT patients with residual masses. With improvements in surgical technique and perioperative care, RPLND is associated with minimal short- and long-term morbidity in the hands of experienced surgeons at dedicated centers. This article reviews the role of RPLND in the management of patients with NSGCT at all stages and its role in advanced seminoma.

A Simple Model for Predicting Nodal Metastasis in Patients With Clinical Stage I Nonseminomatous Germ Cell Testicular Tumors Undergoing Retroperitoneal Lymph Node Dissection Only

PURPOSE

In patients with clinical stage I nonseminomatous germ cell testicular tumor the identification of risk categories for nodal metastases and/or distant metastases could permit selective management. We built 2 models for distinguishing these risk categories.

MATERIALS AND METHODS

Data on 322 consecutive patients with clinical stage I nonseminomatous germ cell testicular tumor patients treated with retroperitoneal lymphadenectomy (RPLND) alone between 1985 and 1995 were analyzed. The interval between orchiectomy and RPLND, vascular invasion (VI), pT stage, percent embryonal carcinoma (ECa) and teratoma in the primary tumor were considered clinically relevant for their association with nodal or distant metastases. Two logistic models were constructed. Model 1 was meant to discriminate 2 patient categories, namely those with and without nodal metastases at RPLND. Model 2 was meant to discriminate 3 patient categories, namely those without any metastases, with nodal metastases only and with distant metastases independent of retroperitoneal metastases. The models were based on these above variables, which were inserted as categorical and then processed through a backward selection procedure.

RESULTS

At RPLND nodal metastases were found in 60 patients (18.6%). During followup distant metastases were observed in 43 patients (13.4%) and retroperitoneal recurrences were noted in 6 (1.9%). Of all recurrences 93.8% were within 2 years since RPLND. RPLND had a high curative rate since 73% of all pN+ cases were cured by surgery alone. The final logistic model 1, including percent ECa and VI, was reassessed in 202 patients with available data. Absent VI and ECa 90% or greater identified a category of 110 patients at low risk for nodal metastasis (14%), while VI and/or ECa greater than 90% identified a category of 92 at higher risk (35%). The identified categories were also related to distant metastases, which occurred in 9.3% of low risk and in 23.1% of high risk cases. Model 2 was not clinically suitable because it did not allow us to distinguish patients at risk for nodal metastases only from those at risk for distant metastases.

CONCLUSIONS

Simplicity is the main advantage of model 1 since only 2 well-known prognostic parameters are involved. Although the model must be validated in an independent case series, the identification of a low risk category with few expected nodal metastases could permit us to replace traditional RPLND with a less invasive staging procedure.

Laparoscopic retroperitoneal lymph node dissection for clinical stage I nonseminomatous germ cell testicular cancer: a long-term update

OBJECTIVES

To assess retrospectively the long-term cancer control in patients undergoing laparoscopic retroperitoneal lymph node dissection (RPLND) in the management of clinical Stage I nonseminomatous germ cell testicular tumors.

METHODS

A retrospective review of 29 patients undergoing laparoscopic RPLND was performed. All patients had clinical Stage I nonseminomatous germ cell testicular tumor, with vascular invasion and/or embryonal carcinoma in the orchiectomy specimen. A modified template dissection was performed. Patients with retroperitoneal metastases were offered two cycles of chemotherapy. A modified follow-up schedule was used in patients with pathologically negative nodes.

RESULTS

Lymph nodes were negative in 17 of 29 patients. Of these 17 patients, 15 had no recurrence and were free of disease with 5.8 years of follow-up. Two patients had recurrence, one in the chest, and one biochemically, and both were free of disease after chemotherapy. Twelve of 29 patients had lymph nodes with metastatic testicular cancer. Ten of these patients underwent adjuvant chemotherapy and were free of disease with 6.3 years of follow-up. One patient had a biochemical recurrence after positive RPLND and was salvaged with chemotherapy. One patient was observed after positive RPLND and was free of disease with 4.9 years of follow-up. The only long-term complication was retrograde ejaculation in 1 patient.

CONCLUSIONS

Laparoscopic RPLND is a safe, minimally invasive treatment option in patients with clinical Stage I nonseminomatous germ cell testicular tumor. The cancer control appears to be similar, with minimal morbidity compared with the open procedure.

Curative treatment of gastric cancer: towards a multidisciplinary approach?

Despite marked decreases in incidence over the last century, particularly in developed countries, gastric cancer is still the second-most common tumor worldwide. Surgery remains the gold standard for the cure of locoregional disease. However, in most countries, the diagnosis is made at an advanced stage, and the 5-year survival for surgically resectable disease stays far below 50%. The efficacy of chemotherapy and/or radiation therapy in addition to surgery has been actively studied over the last 30 years. Unfortunately, with few exceptions, most studies of adjuvant therapy in gastric cancer have given deceiving results. The purpose of this review is to address the reasons for our failure to objectivate an improvement in the cure of gastric cancer with adjuvant treatment in most trials, and to consider potential solutions. The low efficacy of chemotherapy regimens available up to now may have hampered our progress. In addition, many previous studies suffered limitations of design or methodology (e.g. low accrual, inadequate disease stage selection, inadequate surgical treatment) that may have obscured a treatment effect. Furthermore, the reduced treatment tolerance of post-gastrectomy patients, perhaps due to their poor nutritional status, results in decreased or delayed adjuvant systemic therapy, with potential adverse consequences in its efficacy. Among potential solutions, the arrival of new drugs, taxanes and topoisomerase I inhibitors in particular, which have shown encouraging results in metastatic disease, may increase the impact of chemotherapy in a multidisciplinary treatment approach. Pre-treatment with chemotherapy and/or radiation therapy prior to surgery may also be advantageous, averting the problems associated with post-surgical treatment. Such an approach has been shown to be feasible in phase II studies, and is relatively well tolerated by patients. Several carefully designed randomized phase III trials are underway to answer this question.