Heidenreich A, Paffenholz P, Nestler T, Pfister D. Primary and Postchemotherapy Retroperitoneal Lymphadenectomy for Testicular Cancer.
Oncol Res Treat 2018;
41:370-378. [PMID:
29772568 DOI:
10.1159/000489508]
[Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Accepted: 04/23/2018] [Indexed: 11/19/2022]
Abstract
Clinical stage I (CS I) testicular non-seminomatous germ cell tumours (NSGCT) are highly curable. Following orchidectomy, a risk-adapted approach using active surveillance, nerve-sparing retroperitoneal lymph node dissection (RPLND) and primary chemotherapy is recommended by the current guidelines. CS I is defined as showing negative values for tumour markers (or values declining to their half-life following orchidectomy) and negative imaging studies of the chest, abdomen and retroperitoneum. Active surveillance can be performed in low- and high-risk NSGCT with an anticipated relapse rate of about 15% and 50%, respectively. The majority of patients will relapse with good and intermediate prognosis tumours, which have to be treated with 3 to 4 cycles of chemotherapy. About 25-30% of these patients will have to undergo postchemotherapy (PC) RPLND for residual masses. Primary chemotherapy with 1-2 cycles of cisplatin, etoposide, bleomycin (PEB) is a therapeutic option for high-risk CS I NSGCT associated with a recurrence rate of only 2-3% and a minimal acute and long-term toxicity rate. Nerve-sparing RPLND, if performed properly, will cure about 85% of all high-risk patients with CS I NSGCT without the need for chemotherapy. PC-RPLND plays an integral part of the multimodality treatment in patients with advanced testicular germ cell tumours (TGCT). According to current guidelines and recommendations, PC-RPLND in advanced seminomas with residual tumours is only indicated if a positron emission tomography scan performed 6-8 weeks after chemotherapy is positive. In non-seminomatous TGCT, PC-RPLND is indicated for all residual radiographical lesions with negative or plateauing markers. Loss of antegrade ejaculation represents the most common long-term complication, which can be prevented by a nerve-sparing or modified template resection. The relapse rate after PC-RPLND is around 12%; however, it increases significantly to about 45% in cases with redo RPLND and late relapses. Patients with increasing markers should undergo salvage chemotherapy. Only select patients with elevated markers who are thought to be chemo-refractory might undergo desperation PC-RPLND if all radiographically visible lesions are completely resectable. PC-RPLND requires a complex surgical approach and should only be performed in experienced, tertiary referral centres.
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