ROLE OF ADJUVANT CHEMOTHERAPY IN PATIENTS WITH STAGE II NONSEMINOMATOUS GERM-CELL TUMORS

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.

Results of Retroperitoneal Lymph Node Dissection for Clinical Stage I and II Pure Embryonal Carcinoma of the Testis

PURPOSE

We determined the pathological findings and clinical outcome of patients with pure embryonal carcinoma (EC) of the testis managed by primary retroperitoneal lymph node dissection.

MATERIALS AND METHODS

From January 1989 to February 1998, 45 patients with pure EC underwent primary retroperitoneal lymph node dissection at our institution. Patients presented as clinical stage I in 26, IIA in 17 and IIB in 2. Lymphovascular invasion was present in 29 (64%). Median followup was 36.8 months.

RESULTS

Overall the pathological stage was pN0 in 11, pN1 in 10 (4 with microscopic disease) and pN2/N3 in 24 patients (8 with extranodal extension). Nineteen of 26 patients (73%) with clinical stage I and 13 of 17 (77%) patients with clinical stage IIA had retroperitoneal disease. No patient with negative lymph nodes (pN0) has had relapse. Only 1 of 9 (11%) patients with pN1 treated without adjuvant chemotherapy has had relapse. Of 24 patients with pN2/N3 disease only 3 (12%) have required more than 2 cycles of postoperative chemotherapy for persistent or recurrent disease despite complete resection of the retroperitoneum.

CONCLUSIONS

Patients with low stage pure EC of the testis are at high risk for retroperitoneal disease. However these patients do not appear to be at increased risk for high volume (pN2/N3) retroperitoneal disease, systemic relapse in pN0 or pN1 disease managed without adjuvant chemotherapy (although the number of evaluable patients in this subset is somewhat small), or persistent or recurrent disease in completely resected high volume (pN2/N3) retroperitoneal disease compared to patients with mixed nonseminomatous germ cell tumors.

Magnetic resonance imaging and magnetic resonance angiography before postchemotherapy retroperitoneal lymph node dissection

OBJECTIVES

Retroperitoneal lymph node dissection (RPLND) after primary chemotherapy is an accepted therapeutic approach for metastatic nonseminomatous germ cell testicular cancer. Because of the intense desmoplastic reaction and adherence to venous and arterial walls, accurate imaging of the retroperitoneal vasculature and its relation to residual tumor is essential. We report our experience with magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA), including the recently developed technique of bolus-contrast MRA, in patients undergoing postchemotherapy RPLND.

METHODS

Eighteen patients underwent MRI of the retroperitoneal region before RPLND. In addition to routine sequences, MRA was performed in 10 patients, including 8 with a three-dimensional technique using bolus intravenous MR contrast. Results were compared with intraoperative and pathologic findings.

RESULTS

MRI and MRA provided detailed information on retroperitoneal vasculature and its relation to tumor, including multiple renal vessels (n = 5), duplex inferior vena cava (n = 1), left retroaortic renal vein (n = 2), and common iliac vein thrombus (n = 1). In all cases, bolus-contrast MRA provided unique information on the location and number of renal and lumbar arteries, in addition to information on the aorta and the mesenteric and iliac vessels. The origin and number of renal arteries were accurately identified in all patients by bolus-contrast MRA; 2 patients had supernumerary renal arteries discovered at RPLND that had not been identified on non-bolus-contrast MRI.

CONCLUSIONS

Bolus-contrast three-dimensional MRA provides unique information on renal and lumbar vessels. The potential benefit of avoiding vascular injury during dissection should be prospectively evaluated.

Role for retroperitoneal lymphadenectomy for testis cancer

There continue to be several controversies surrounding the role for retroperitoneal lymphadenectomy (RPL) in the management of patients with germ cell cancer of the testis. The initial treatment options for those with clinical stage I disease are surveillance (orchiectomy only), RPL or chemotherapy. Survival rates are similar with RPL and surveillance. Surgical morbidity has been reduced as techniques for RPL continue to improve. The likelihood of early or late (> 2 years) recurrence in the retroperitoneum is almost eliminated by RPL. Fewer follow-up computerized tomography scans of the abdomen are required and there are opportunities to reduce the duration and methods of follow-up, compared with surveillance. For patients with stage II disease, chemotherapy and RPL are equally effective initial treatment options but many patients require a combined approach. Initial RPL should be reserved for patients with smaller volume disease and possibly with lower preoperative marker levels. With RPL, patients are accurately staged and cured most of the time without double treatment. Approximately 30% of those with larger masses will have residual disease after initial chemotherapy and will require RPL as a second treatment. The third indication for RPL is to excise residual retroperitoneal masses following primary chemotherapy. Models to predict the presence of residual viable tumor, rather than necrosis only, at the time of surgery have been developed. If the orchiectomy specimen contained no teratoma, the tumor markers normalize after three or four courses of chemotherapy, and if the residual mass on computerized tomography scan is less than 2 cm in diameter, the rate of viable tumor may be low enough to omit RPL. In this way, the greater morbidity often associated with post-chemotherapy RPL may be avoided.

A rational approach to managing stage I nonseminomatous germ cell cancer

Regardless of the treatment option selected for management of low-stage germ cell cancer, ultimate survival is nearly identical. Treatment-related morbidity is very low regardless of management modality and the individual patient can expect similar physical limitations owing to therapy. The overall difference in loss of productivity between treatment programs varies by little more than 1 week. The cost of treatment is similar for all methods, although there is a definite financial advantage to surveillance, less so for selective surveillance, when compared with other forms of management. Socioeconomic factors are of importance when managing limited resources for a large population, but are of less concern to an individual, especially when the mean differences in per patient costs vary by only $5000. Because of these close similarities in efficacy, morbidity, and costs treatment decisions should be individualized. A responsible and reliable patient can be managed safely by selective surveillance. Those individuals considered to be less self-motivated to pursue intensive care should be managed by primary therapy. Without more information regarding the long-term outcomes associated with primary adjuvant chemotherapy, primary adjuvant RPLND, where experienced surgical support is available, is the preferred management for low-stage germ cell cancer in patients selected for, or electing, active treatment rather than surveillance. Active investigations examining the role of medical management in this population should be continued. Our preferred choice of initial management is to offer selective surveillance to appropriate patients and modified RPLND to the remainder.

Laparoscopic approach to retroperitoneal lymph node dissection

Laparoscopic retroperitoneal lymph node dissection is a new surgical procedure used to enhance staging in men with clinical stage I nonseminomatous germ cell tumors of the testis. The procedure has been performed in a limited number of patients at several centers with extensive laparoscopic experience. Laparoscopic retroperitoneal lymphadenectomy is a technically demanding procedure which can be successfully completed in the majority of patients. However, the risk of complications is greater than in patients who undergo standard open retroperitoneal lymph node dissection. The primary advantage of a laparoscopic approach is shortened hospitalization and rapid return to normal activity. The role of laparoscopy in the management of patients with testis malignancy has not been defined. The use of this staging procedure may help minimize the need for surveillance studies following surgery and may be best utilized in men with a lower likelihood of nodal metastases. Ultimately, prospective study in large groups of patients will be necessary to determine the role of laparoscopic retroperitoneal lymph node dissection in patients with testis cancer.

Secondary tumours following etoposide containing therapy for germ cell cancer

BACKGROUND

Reports have implied etoposide as the cause of secondary leukaemia in patients treated for germ cell cancer.

PATIENTS AND METHODS

Between 1979 and 1992, 679 male patients with germ cell cancer received etoposide containing chemotherapy.

RESULTS

Six of 679 patients developed acute myeloid leukaemia (relative risk 150; CI: 55-326). None of these patients had a primary mediastinal germ cell tumour and only 1 patient received previous radiotherapy. The median interval between the onset of cytotoxic treatment and the development of leukaemia was 27 months. The FAB M4 morphology was seen in 4 of 6 cases.

CONCLUSION

The benefit of etoposide containing protocols outweigh the risk of leukaemia in patients with intermediate or high risk disease, however in patients with good risk disease non-etoposide containing protocols should be explored.

Laparoscopic retroperitoneal lymphadenectomy: multi-institutional analysis

Modified unilateral laparoscopic retroperitoneal lymph node dissection was attempted in 20 patients with nonseminomatous testicular cancer. The procedure was completed in 18 men at a median operative length of 6 hours. Median estimated blood loss was 250 cc and median number of lymph nodes removed was 14.5. Nodal disease spread was noted in 3 of 18 patients (17%). Most patients were hospitalized for 3 days or less and had returned to normal activity levels within 2 to 3 weeks. Antegrade ejaculation was preserved in all 20 patients. Significant complications occurred in 6 of 20 patients (30%), with bleeding being the most common adverse event encountered. In 2 patients an abdominal incision and completion of the procedure by open retroperitoneal lymph node dissection were required due to significant bleeding following injury to the gonadal vessels. With a median followup of 10 months (range 2 to 25), 2 men had pulmonary disease recurrence and none had abdominal recurrence. Laparoscopic retroperitoneal lymph node dissection can be completed successfully in patients with stage I testicular cancer and may be most appropriate in those with limited risk of metastatic disease spread. The morbidity may be largely attributed to a steep learning curve. The efficacy of laparoscopic retroperitoneal lymph node dissection compared with standard techniques and determination of its role in patients with testicular cancer will require longer followup in larger groups of patients.

Laparoscopic retroperitoneal lymphadenectomy for high-risk stage 1 nonseminomatous germ cell tumor: report of four cases

OBJECTIVE

To evaluate in a prospective fashion the feasibility of performing retroperitoneal lymphadenectomy (RPL) for high-risk Stage 1 nonseminomatous germ cell tumors (NSGCT) using a laparoscopic technique, and to compare the results to historical controls.

METHODS

RPL was performed laparoscopically on patients with Stage 1 NSGCT: Each patient had pathologic risk factors associated with an increased likelihood of metastases, and radiologic investigations revealed no evidence of retroperitoneal or distant disease. A modified template lymphadenectomy was performed in each case. The results of these four operations were compared to eight open RPLs performed on a similar group of patients.

RESULTS

In 3 of the 4 cases, a thorough dissection was possible. In 1 of these 3, an open laparotomy was required to repair a caval laceration resulting from avulsion of a small lumbar vein at the end of the laparoscopic dissection. Compared to the open approach, there was considerably less postoperative morbidity.

CONCLUSIONS

This procedure may represent an alternative approach to surveillance or open RPL for high-risk Stage 1 patients. Further experience is required to determine the sensitivity and effectiveness of this procedure compared to open RPL before its role in clinical practice can be established.