Distribution of nodal metastases after chemotherapy in nonseminomatous testis cancer: a possible indication for limited dissection

Postchemotherapy Retroperitoneal Lumpectomy in Patients with Nonseminoma Testicular Cancer: A Nationwide Study

BACKGROUND AND OBJECTIVE

Optimal treatment outcomes in patients with metastatic nonseminoma testicular cancer are achieved with chemotherapy and subsequent surgery in cases with residual tumor. In Denmark, postchemotherapy retroperitoneal lumpectomy (RPLP) is performed in patients with residual tumors >1 cm. There is a need to clarify whether this surgical method provides acceptable treatment results. Our objective was to describe morbidity and oncological outcomes of postchemotherapy RPLP.

METHODS

This was a retrospective population-based multicenter study including patients with nonseminoma testicular cancer and postchemotherapy RPLP performed in Denmark between 1990 and 2015. A total of 219 patients were eligible, with median follow-up of 19 yr. Postoperative complications were evaluated according to the Clavien-Dindo classification. The cumulative incidence of recurrence inside or outside the borders of a bilateral surgical template, progression-free survival (PFS), and overall survival estimates were calculated using the Kaplan-Meier method.

KEY FINDINGS AND LIMITATIONS

After median follow-up of 19 yr, 31/219 patients (14%) experienced a surgical complication, of which 5% were Clavien-Dindo grade ≥III. In total, 37 patients experienced a recurrence. The 5-yr, 10-yr, and 20-yr cumulative risk of recurrence inside a bilateral template was 4.3%, 5.9%, and 5.9%, respectively. The 10-yr PFS rate was 83% and the 10-yr overall survival rate was 96%. The main limitation of the study is the retrospective design.

CONCLUSIONS AND CLINICAL IMPLICATIONS

With few patients experiencing a major postoperative complication and a 10-yr cumulative rate of 5.9% for recurrence inside a bilateral surgical template, postchemotherapy RPLP appears to be a safe alternative to template surgery for disseminated nonseminoma.

PATIENT SUMMARY

We looked at minimal surgery to remove tumor tissue remaining after chemotherapy in patients with testicular cancer. We found a low frequency of complications, tumor recurrence, and death.

Lymph Node Dissection in Testicular Cancer: The State of the Art and Future Perspectives

PURPOSE OF REVIEW

This narrative review provides a comprehensive overview of the evolving role of retroperitoneal lymph node dissection (RPLND) in the management of testicular cancer (TC). It explores the significance of RPLND as both a diagnostic and therapeutic tool, highlighting its contribution to accurate staging, its impact on oncological outcomes, and its influence on subsequent treatment decisions.

RECENT FINDINGS

RPLND serves as an essential diagnostic procedure, aiding in the precise assessment of lymph node involvement and guiding personalized treatment strategies. It has demonstrated therapeutic value, particularly in patients with specific risk factors and disease stages, contributing to improved oncological outcomes and survival rates. Recent studies have emphasized the importance of meticulous patient selection and nerve-sparing techniques to mitigate complications while optimizing outcomes. Additionally, modern imaging and surgical approaches have expanded the potential applications of RPLND. In the context of TC management, RPLND remains a valuable and evolving tool. Its dual role in staging and therapy underscores its relevance in contemporary urological practice. This review highlights the critical role of RPLND in enhancing patient care and shaping treatment strategies, emphasizing the need for further research to refine patient selection and surgical techniques.

Post-chemotherapy modified template retroperitoneal lymph node dissection in patients with nonseminomatous germ cell tumours

INTRODUCTION/BACKGROUND

Although a full bilateral template RPLND is thought to be the standard of care for the management of postchemotherapy retroperitoneal residual masses for nonseminomatous germ cell tumors (NSGCT), in the past decade modified templates have become increasingly popular. In this study, we aimed to present our oncological and perioperative outcomes of consecutive seventeen NSGCT patients who underwent a modified template unilateral PC-RPLND for retroperitoneal residual disease.

MATERIALS AND METHODS

We retrospectively evaluated the medical records of 17 consecutive NSGCT patients who underwent modified template unilateral PC-RPLND in our university hospital between 2017 and 2020. All patients had normal serum tumour markers with residual disease in the retroperitoneum. Surgical characteristics including the size of the retroperitoneal residual mass, residual tumor pathology, removed lymph nodes, positive percentage of removed lymph nodes, accompanying operations, complications, mean operation time and hospital stay, and long-term results including survival and antegrade ejaculation were evaluated.

RESULTS

Eleven patients underwent left and six right-sided surgery. Median residual lymph node diameter was 41mm. Median hospitalisation time was 3.5 days. Median follow-up time was 10.5 months. Necrosis/fibrosis was seen in 6 patients, and teratoma in 11 patients. No viable tumour was seen. No patients died in the follow-up period. None of the patients relapsed during follow-up. Ten/seventeen patients had antegrade ejaculation.

CONCLUSIONS

Modified template unilateral PC-RPLND leads to very good oncological outcomes with decreased perioperative morbidity as well as better antegrade ejaculation rates. Low volume retroperitoneal disease seems to fit this procedure best.

Unilateral or Bilateral Retroperitoneal Lymph Node Dissection in Nonseminoma Patients with Postchemotherapy Residual Tumour? Results from RETROP, a Population-based Mapping Study by the Swedish Norwegian Testicular Cancer Group

BACKGROUND

The distribution of retroperitoneal lymph node metastases for patients with nonseminoma and a residual tumour of 10-49 mm in a population-based setting is unknown. This information is needed to justify selection of patients for a unilateral template resection.

OBJECTIVE

To describe the location of retroperitoneal metastases and recurrences in patients with nonseminoma germ cell tumour (NSGCT) with a residual tumour of 10-49 mm.

DESIGN, SETTING, AND PARTICIPANTS

RETROP is a population-based prospective observational mapping study of 213 patients in Sweden and Norway with a retroperitoneal residual tumour of 10-49 mm who underwent postchemotherapy retroperitoneal lymph node dissection for metastatic NSGCT during 2007-2014 with median follow-up of 100 mo. Patients were classified according to the testis primary tumour and the distribution of unilateral or bilateral lymph node metastases (with reference to the aorta) present on pre- and/or postchemotherapy computed tomography (CT) scans.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The distribution and rate of teratoma or cancer in unilateral or bilateral retroperitoneal fields and the location and rate of retroperitoneal recurrence were measured.

RESULTS AND LIMITATIONS

In total, 65% of the patients had unilateral retroperitoneal lymph node metastases (RLNMs) on CT scans. Patients with unilateral RLNMs had a low risk of contralateral teratoma or cancer (1.6% for right- and 2.6% for left-sided NSGCT) or retroperitoneal recurrence (0% for right- and 4% for left-sided NSGCT). A weakness of the study is that the pathology specimen could not be fully designated to one specific area for some of the patients.

CONCLUSIONS

Men with postchemotherapy residual disease of 10-49 mm and unilateral metastases on pre- and postchemotherapy CT scans have a low risk of contralateral disease and should be considered for a unilateral template resection.

PATIENT SUMMARY

The surgeon can use computed tomography (CT) scans in deciding on the extent of lymph node dissection in patients with testicular cancer.

Oncological outcome and complications of post-chemotherapy retroperitoneal surgery in non-seminomatous germ cell tumours - a systematic review

INTRODUCTION

Post-chemotherapy surgery constitutes an integral part of the management of patients with non-seminomatous germ-cell tumours with a residual mass in the retroperitoneum. Published data on recurrence rates and complications to bilateral retroperitoneal lymph node dissection (RPLND), unilateral template RPLND, and resection of residual mass only according to different surgical techniques (open, laparoscopic, and robotic surgery) were reviewed.

MATERIAL AND METHODS

PubMed/Medline, Embase, and the Cochrane databases were searched systematically. The risk of bias was assessed with the Newcastle Ottawa Scale.

RESULTS

In total, 28 studies were included. Eight studies reported on open surgery with the bilateral template, seven on the unilateral template, and three on resection of mass only. Median follow-up was 39, 39, and 70 months, respectively. Recurrences were found in 11, 12, and 14%, respectively. Major complications (Clavien-Dindo III or more) were observed in 18, 8, and 17%, respectively. Two studies reported on laparoscopic bilateral surgery, eight on unilateral, and two on residual mass only. A total of Median follow-up was 52, 29, and 55 months, respectively. Recurrences were found in 0, 1, and 9%, respectively. Major complications were not documented for bilateral but were observed in 4% for unilateral and 0% for resection of tumour only. Four studies on robotic bilateral surgery, three on unilateral and two on resection of tumour only were included. Follow-up was 18, 35, and 30 months, respectively. Recurrences were found in 0, 0, and 2%, respectively. Major complications were observed in 0, 10. and 2%, respectively.

CONCLUSIONS

When patient selection is made, recurrence rates for the open unilateral template are comparable to the bilateral template. The risk of complications is highest after an open bilateral template. Laparoscopic and robotic surgery should not be used as a standard procedure. More studies are required with larger patient populations and longer follow-up.

Clinical dilemmas in local and regional testis cancer

At the Canadian Testis Cancer Workshop, the multidisciplinary management of testis cancer care was discussed. The two-day workshop involved urologists, medical and radiation oncologists, pathologists, radiologists, physician's assistants, residents, fellows, nurses, patients, and patient advocacy group members.This review summarizes the discussion regarding clinical dilemmas in local and regional testis cancer. We present cases that highlight the need for a coordinated approach to individualize care. Overarching themes include the importance of a multidisciplinary approach to testis cancer, willingness to involve a high-volume experienced center, and given that the oncological outcomes are excellent, a reminder that clinical decisions need to prioritize selecting a strategy with the least treatment-related morbidity when safe.

Clinical outcome of post-chemotherapy retroperitoneal lymph node dissection in metastatic nonseminomatous germ cell tumour: A systematic review

Post-chemotherapy retroperitoneal lymph node dissection (PC-RPLND) is an important element of the management of patients with residual tumour after chemotherapy for disseminated nonseminomatous germ cell tumour (NSGCT). This is a challenging procedure and the outcome varies widely between institutions. There is much debate concerning the anatomical extent of the dissection and the literature is conflicting regarding the outcome of this procedure. In this systematic review we aim to summarise the literature on the relapse rate of PC-RPLND. We performed a search of the literature of the PubMed/MEDLINE and Embase databases, in accordance with the PRISMA guidelines. Studies reporting on the relapse rate of PC-RPLND in NSGCT patients with residual tumour were eligible for inclusion. We calculated the weighted average relapse rates of included studies and assessed the risk of bias using the Newcastle-Ottawa scale. A total of 33 studies, reporting on 2,379 patients undergoing open PC-RPLND (O-RPLND) and 463 patients undergoing minimally invasive PC-RPLND (MI-RPLND) were included. The weighted average relapse rates were 11.4% for O-RPLND, and 3.0% for MI-RPLND. The rates of retroperitoneal relapse were 4.6% and 1.7% after O-RPLND and MI-RPLND, respectively. For O-RPLND specifically, the average retroperitoneal relapse rate was 3.1% after modified dissection and 6.1% after bilateral dissection. We conclude that modified template dissection is oncologically safe in carefully selected patients. Minimally invasive procedures are feasible but long-term data on the oncological outcome are still lacking. PC-RPLND is a complex and challenging procedure, and patients should be treated at high-volume expert centres.

Robotic Postchemotherapy Retroperitoneal Lymph Node Dissection for Testicular Cancer

BACKGROUND

Postchemotherapy retroperitoneal lymph node dissection (pcRPLND) is mandated in patients with nonseminomatous germ cell tumor found to have residual masses after chemotherapy. Performed via the open approach, pcRPLND can incur significant perioperative morbidity.

OBJECTIVE

To demonstrate the feasibility of robotic pcRPLND (r-pcRPLND) and provide evidence for its selection criteria.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective search identified 93 patients undergoing pcRPLND between April 2007 and March 2018, comprising 30 r-pcRPLND and 63 open pcRPLND (o-pcRPLND) procedures performed by a single surgeon.

INTERVENTION

r-pcRPLND and o-pcRPLND.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Baseline clinicopathologic characteristics and intraoperative variables including operating room (OR) time, estimated blood loss (EBL), resection of adjacent organs, and intraoperative consultation with other surgical services were recorded. Hospital length of stay (LOS) and perioperative complications were assessed as per the Clavien-Dindo classification, and oncologic outcomes such as nodal yield, histologic distribution, pathologic staging, time to recurrence, and cancer-specific survival were compared.

RESULTS AND LIMITATIONS

r-pcRPLND was performed in a well-selected cohort with lower clinical stage (p=0.006), favorable International Germ Cell Cancer Collaborative Group classification (p=0.01), and smaller retroperitoneal mass (p=0.001). o-pcRPLND required more frequent bilateral template dissection (88.9% vs 43.3%; p<0.001), resection of adjacent organs (36.5% vs 10%; p=0.007), consultation with other surgical services (46% vs 2%; p<0.001), and auxiliary procedures (54.0% vs 20%; p=0.003) to achieve complete oncologic control. OR time was similar between the two groups (o-pcRPLND 375min vs r-pcRPLND 388min; p=0.16) and EBL was significantly lower in r-pcRPLND (234 vs 825ml; p<0.001). Median LOS was significantly shorter after r-pcRPLND (2 vs 7d; p<0.001). A total of 31 patients (33%) suffered postoperative complications, of whom 18 (19.4%) had major complications. Nodal yield was similar (o-pcRPLND 23 vs r-pcRPLND 24; p=0.8). The distribution of lesion histology (necrosis/teratoma/GCT) was also similar pcRPLND (o-pcRPLND 25.4%/57.1%/17.4% vs r-pcPLND 33.3%/50%/16.7%; p=0.51). Overall, tumor recurred in 15 patients (16.1%), including three following r-pcRPLND (10%), all outside the operative field. On univariate analysis, surgical approach was not a significant predictor of time to recurrence (p=0.34). One limitation was that antegrade ejaculation was not assessed.

CONCLUSIONS

With rigorous patient selection, r-pcRPLND can be safely performed and may reduce perioperative morbidity while maintaining oncologic proficiency.

PATIENT SUMMARY

Resection of residual retroperitoneal mass after chemotherapy in patients with metastatic testicular cancer can be performed safely via a robotic approach. Robotic surgery can reduce the morbidity of the procedure.

Management of residual masses in testicular germ cell tumors

INTRODUCTION

About 50% of all patients with advanced testicular cancer demonstrate residual retroperitoneal or extraretroperitoneal masses. About two thirds of the masses harbour necrosis/fibrosis only whereas as about 10% and 40% harbour vital cancer or teratoma. Appropriate therapy will result in a high cure rate if performed properly. Areas covered: This review article covers the indication, the surgical technique and the oncological outcome of PC-RPLND and resection of extraretroperitoneal residual masses following chemotherapy in patients with advanced testis cancer. Expert commentary: Postchemotherapy retroperitoneal lymph node dissection (PC-RPLND) plays an integral part of the multimodality treatment in patients with advanced testicular germ cell tumours. Patients with nonseminomas, residual masses < 1cm and good prognosis can undergo active surveillance. In all other cases, PC-RPLND with or without resection of adjacent organs needs to be performed for curative intent. PC-RPLND requires a complex surgical approach and should be performed in experienced, tertiary referral centres only.

Therapeutic supine robotic retroperitoneal lymph node dissection for post-chemotherapy residual masses in testicular cancer: technique and outcome analysis of initial experience

Retroperitoneal lymph node dissection (RPLND) is a therapeutic standard of care for post-chemotherapy residual masses in testicular cancer. While a robotic approach to this procedure has the potential of decreasing the morbidity associated with this major endeavour, it is often criticised for its inability to provide a bilateral complete template resection without redocking and repositioning the patient. Herein, we present the technique and initial outcomes of a supine approach to Robotic RPLND (R-RPLND) using the da Vinci Xi^® system, which obviates the need for repositioning or redocking for a bilateral full template resection. Three patients (age 21-36) with nonseminomatous germ cell tumours of the testis underwent R-RPLND for post-chemotherapy residual retroperitoneal masses with normalised tumor markers. Salient steps of the procedure were as follows: port placement in supine Trendelenburg position, docking of the da Vinci Xi^® system from one side, exposure of retroperitoneum, dissection of paracaval, retrocaval, interaortocaval, paraaortic and bilateral common iliac templates, and excision of gonadal vein. Mean console time and estimated blood loss were 257 (190-305) minutes and 333 (300-400) ml, respectively. Mean lymph node yield was 52 (29-94). One patient had a common iliac vein injury which was managed robotically without further consequence. No drains were placed in all three. There were no postoperative complications and all of them were advanced to a normal diet within 24 h and discharged on the second postoperative day. Histopathology reports were suggestive of necrosis and mature teratoma without any viable tumour. There have been no recurrences in these patients at a mean follow-up of 14 (1-22) months. R-RPLND in the supine position is practical, safe and feasible in the post-chemotherapy setting of testicular cancer. It eliminates the need for repositioning the patient or redocking the robot to achieve a complete resection with adequate lymph node yields, while preserving the benefits of a minimally invasive surgical approach.

[When is surgical resection of metastases in testicular germ cell tumors indicated and is there a scientific basis?]

Surgical resection of metastases represents an integral part of curative management in patients with testicular germ cell tumors (GCT). Primary nerve-sparing retroperitoneal lymph node dissection (nsRPLND) for low volume metastases in clinical stages I-IIB has to be differentiated from the more complex and more extensive postchemotherapeutic procedures. In Europe, primary nerve-sparing retroperitoneal lymph node dissection (nsRPLND) for clinical stage I nonseminomatous GCT (NSGCT) plays a subordinate. In clinical stage IIA/B, nsRPLND is indicated for patients with marker-negative metastases in whom cure rates of about 65% can be achieved with surgery alone. For clinical stage IIA/B seminomas, nsRPLND represents an individual, still experimental procedure with high cure rates. Postchemotherapy residual tumor resection (pRTR) for advanced seminomas is only indicated in the context of a FDG-PET/CT-positive residual mass >3 cm in diameter. For NSGCT, pRTR is indicated in patients with residual masses >1 cm and negative or plateauing tumor markers to resect persisting teratoma or vital cancer. Complete resection of all masses including resection of adjacent vascular, visceral or skeletal metastases is mandatory to achieving the highest cure rate possible. Due to the complexity and the lower rate of significant morbidity and mortality, these procedures should be done at tertiary referral centers.

Robot-assisted retroperitoneal lymph node dissection: Feasibility and outcome in postchemotherapy residual mass in testicular cancer

INTRODUCTION

We aimed to evaluate the surgical feasibility, complication, and oncological outcome of robot-assisted retroperitoneal lymph node dissection (RA-RPLND) in patients of testicular tumor with postchemotherapy residual retroperitoneal mass.

METHODS

A total of 13 patients underwent RA-RPLND between January 2012 and September 2016 at our institute. A study was started on December 2015, so data were collected retrospectively and prospectively regarding patient demography, tumor characteristics, surgical, pathological outcome, and oncological outcome.

RESULTS

RA-RPLND was successfully completed in all the 13 patients. Lateral approach was used in initial 12 patients with unilateral dissection in 11 patients and bilateral dissection after in 1 patient after repositioning in bilateral position. Supine robotic approach used in 1 patient. Median operative time was 200 min, median estimated blood loss was 120 ml, and median length of hospital stay was 4 days. The median yield of lymph node was 20. Three patients had positive lymph nodes, all had teratoma germ cell tumor. Ten patients had only necrosis in lymph nodes. After median follow-up 23 months (range 3-58 months), no systemic or retroperitoneal recurrence was found. Four patients developed chyle leak. One patient was managed conservatively with diet modification, one with intranodal lipiodol lymphangiography and two patients were managed surgically.

CONCLUSION

RA-RPLND is safe and feasible for postchemotherapy residual mass with accepted compilation rate, but larger studies are required to establish its diagnostic and therapeutic utility along with safety of the procedure.

Post chemotherapy retroperitoneal lymph node dissection in germ cell tumor: robotic way

Post chemotherapy residual masses are considered extremely challenging to remove even by the most experienced laparoscopic surgeons. Robotic technology has added a new dimension to the management of such cases and has lessened the fear and discomfort associated with such challenging surgery but is still evolving. We present our experience of management of post chemotherapy residual mass with robotic assistance along with tips and tricks required to perform such procedure.

Advances in the treatment of testicular cancer

Germ cell tumors (GCT) are relatively uncommon, accounting for only 1% of male malignancies in the United States. It has become an important oncological disease for several reasons. It is the most common malignancy in young men 15-35 years old. GCTs are among a unique numbers of neoplasms where biochemical markers play a critical role. Finally, it is a model of curable cancer. In this review we discuss cancer epidemiology, genetics, and therapeutic principles. Recent advances in the management of stage I GCT and controversies in the management of post chemotherapy residual mass are presented.

Postchemotherapy surgery for germ cell tumors--what have we learned in 35 years?

Postchemotherapy surgery for advanced testicular cancer has evolved over the last couple of decades. Patients with nonseminomatous germ cell tumors and residual retroperitoneal mass ≥1 cm should undergo postchemotherapy retroperitoneal lymph node dissection (RPLND). For seminoma, RPLND is considered in those patients with masses ≥3 cm that are also positron emission tomography positive. Masses that occur outside of the retroperitoneum should be completely resected with the possible exception of bilateral lung masses when resection of the first mass shows necrosis. The role of surgery in patients with extragonadal germ cell tumors is most vital in those with primary mediastinal nonseminomatous germ cell tumors. Importantly, patient selection, surgical planning, and consideration of referral to centers with this expertise are important to optimize success.

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 and resection for testicular cancer: an update on best practice

Clinical stage I testicular nonseminomatous germ cell tumours (NSGCTs) are highly curable. Following orchidectomy a risk-adapted approach using active surveillance (AS), nerve-sparing retroperitoneal lymph node dissection (nsRPLND) and primary chemotherapy is recommended by the current guidelines. Clinical stage I is defined as negative or declining tumour markers to their half-life following orchidectomy and negative imaging studies of the chest, abdomen and retroperitoneum. Active surveillance can be performed in low-risk and in high-risk NSGCTs with an anticipated relapse rate of about 15% and 50%. The majority of patients will relapse with good and intermediate prognosis tumours which have to be treated with three to four cycles chemotherapy. About 25-30% of these patients will have to undergo postchemotherapy retroperitoneal lymph node dissection (PC-RPLND) for residual masses. Primary chemotherapy with one or two cycles of cisplatin (Platinol), etoposide and bleomycin (PEB) is a therapeutic option for high-risk clinical stage I NSGCT associated with a recurrence rate of only 2-3% and a minimal acute and long-term toxicity rate. nsRPLND, if performed properly, will cure about 85% of all high-risk patients with clinical stage I NSGCT without the need for chemotherapy. PC-RPLND forms an integral part of the multimodality treatment in patients with advanced testicular germ cell tumours (TGCTs). According to current guidelines and recommendations, PC-RPLND in advanced seminomas with residual tumours is only indicated if a positron emission tomography (PET) scan performed 6-8 weeks after chemotherapy is positive. In nonseminomatous TGCT, PC-RPLND is indicated for all residual radiographic 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 chemorefractory might undergo desperation PC-RPLND if all radiographically visible lesions are completely resectable. PC-RPLND requires a complex surgical approach and should be performed in experienced, tertiary referral centres only.

[Postchemotherapy retroperitoneal lymphadenectomy for testicular cancer. Literature review by the Oncology Committee of the French Association of Urology, External Genitalia Group]

INTRODUCTION

Postchemotherapy retroperitoneal lymphadenectomy (PC RPLDN) leads to an overall survival rate for testicular cancer exceeding 75%. Several questions still persist concerning: preoperative assessment of residual masses, reducing templates of dissection, choosing surgical approaches or including RPLND in high-risk patients' management.

METHOD

The main series in the literature of the past 20 years were analyzed and selected to address these issues and reach a consensual diagnostic and therapeutic approach.

RESULTS

Forty-eight original articles (1992 to 2011) were selected. They confirm that no preoperative tool can predict the histological nature of residual masses. The unilateral modified template is a valid option for selected patients but the full bilateral dissection remains the standard but more morbid. The laparoscopic approach is being evaluated. The LDNRP PC is indicated in "high risk" situations especially after salvage chemotherapy.

CONCLUSION

The bilateral lymphadenectomy by laparotomy of any supracentimeter residual mass, 6 weeks after chemotherapy, for germ cell tumors of the testicle is a standard of care.

[What is new in 2011 regarding testicular cancer]

The management of testicular cancer has already been standardized to the greatest extent by consistent performance of clinical trials. While the current aim is to reduce the therapy for early stage disease without jeopardizing the high cure rates, for patients in advanced stages the goal is to achieve further improvement of survival rates. This overview presents new aspects of organ-preserving primary tumor resection, prognostic factors in seminoma, secondary malignancies, high-dose therapy, residual tumor resection, aftercare, and PET/CT.

Management of post-chemotherapy residual mass in patients with metastatic nonseminomatous germ cell tumors of the testis

The basis of treatment for advanced germ cell tumors is chemotherapy and surgical resection of residual disease. Surgery has maintained its role in staging and therapeutic management. Despite these advances, much of the outcomes depend on proper patient selection. Complete removal of all post-chemotherapy residual masses remains the standard of care in the treatment of advanced nonseminomatous germ cell tumors both within and outside of the retroperitoneum.

[The surgery after. . . retroperitoneal lymph node dissection and surgery of the residual masses after chemotherapy for advanced testicular cancer]

Thirty-six cases of retroperitoneal lymph node dissections for residual mass after chemotherapy for testicular cancer are reported. In a reference center, the recruitment is modified by the severity of the situations related to very big masses, tumors of poor prognosis and resistant tumors. Lymph node dissection is often atypical and surgery of metastatic residual masses is frequent (13 operations). The 8-year global survival remains stable, over 90%. The 5-year cumulated risk of recurrence is 20%, but these situations can be overtaken.

Postchemotherapy laparoscopic retroperitoneal lymph node dissection in nonseminomatous germ-cell tumor

BACKGROUND AND PURPOSE

Postchemotherapy retroperitoneal lymph node dissection (RPLND) remains essential in the management of metastatic testicular carcinoma and represents a surgical challenge. We determined to assess the feasibility and complications of laparoscopic RPLND in patients who were treated with induction chemotherapy for testis cancer.

PATIENTS AND METHODS

We performed a retrospective analysis of data that was prospectively recorded from 26 patients who underwent laparoscopic RPLND postplatinum-based chemotherapy between 2000 and 2006. The surgical technique consisted of excision of the residual mass plus unilateral template dissection. A transperitoneal technique was used in 24 patients, and an extraperitoneal approach was used in 2 patients. Operative details, perioperative morbidity data, and histologic findings were assessed for the study.

RESULTS

Primary pathologic evaluation of the testis tumor revealed pure embryonal carcinoma in 4 patients, teratocarcinoma in 1 patient, and mixed nonseminomatous germ-cell tumors in 21 patients. All patients had residual disease in the retroperitoneum on a preoperative CT scan, with a median size of 3.4 cm (range 2-6 cm). Procedures in three (11.5%) patients were converted to open surgery. Median operative time was 183 minutes (range 120-260 min). Median estimated blood loss was 400 mL (range 100-600 mL), and blood transfusion was necessary in one patient. Median hospital stay was 5 days (range 2-6 d). Median number of lymph nodes obtained on final histologic examination was 7 (range 4-13). Perioperative complications included eight lymphovascular and one intestinal. At a mean follow-up of 27 months (range 14-36 mos), no recurrences have been observed and no patient was lost to follow-up.

CONCLUSIONS

Postchemotherapy laparoscopic RPLND is technically feasible. The most frequent complications and causes of conversion are lymphovascular.

[Surgical management of retroperitoneal metastases from germ cell cancers]

The surgery of residual retroperitoneal tumors is a compulsory prolongation of chemotherapy in non seminomatous germ cell tumors. The requirements of total resection must be respected. High morbidity of bilateral lymphadenectomy for large bulky disease is possible and implies specialised surgery. The extent of surgery can be limited to a template area in specific circumstances.

Postchemotherapy retroperitoneal lymph node dissection in advanced testicular cancer: radical or modified template resection

BACKGROUND

The anatomical extent of postchemotherapy retroperitoneal lymph node dissection (PC-RPLND) has been discussed controversially for many years.

OBJECTIVE

To evaluate the necessity of PC-RPLND with modified or radical template resection in patients with advanced nonseminomatous germ-cell tumors (NSGCT) and residual masses following systemic chemotherapy.

DESIGN, SETTING, AND PARTICIPANTS

The charts of 152 consecutive patients who were treated at two tertiary referral centers were retrospectively reviewed.

INTERVENTION

All patients underwent PC-RPLND, with 54 and 98 patients undergoing a radical template resection and 98 patients undergoing a modified template resection. Modified template resection was performed if the location of the residual mass corresponded to the primary landing zone of testis cancer and the residual mass measured < or = 5 cm in diameter. In all other cases a full bilateral PC-RPLND was chosen.

MEASUREMENTS

The following data were analyzed: location of the residual mass, extent of surgery, length of surgery, treatment-associated complications, nerve-sparing approach, adjunctive surgical procedures, postoperative morbidity, duration of hospital stay, early and late complications, relapse rates, cancer-specific survival rates, and overall survival rates.

RESULTS AND LIMITATIONS

Overall, 84 patients (55.2%) had necrosis/fibrosis, 45 (29.6%) had mature teratoma, and 23 (15.1%) had vital cancer in the surgical specimens. Antegrade ejaculation was preserved in 85% and 25% of patients undergoing modified and bilateral PC-RPLND (p=0.02), respectively. Eight recurrences (5.2%) were observed after a mean follow-up of 39 mo (range 6-105 mo): one patient had an in-field relapse following modified PC-RPLND, and seven patients had recurrences outside the boundaries of full bilateral PC-RPLNDs. The 2-yr disease-free survival rates were 78.6% and 92.8% for bilateral and modified PC-RPLND, respectively. The limitations of this study were a short follow-up, a limited number of patients, and the retrospective nature of the study.

CONCLUSIONS

Full bilateral PC-RPLND is the standard approach to extensive residual masses. In well-defined masses a modified template PC-RPLND does not interfere with oncologic outcome but decreases treatment-associated morbidity.

Testicular germ cell tumors

PURPOSE OF REVIEW

Preclinical and clinical developments in germ cell tumors over the past year are summarized.

RECENT FINDINGS

Attenuations in the rising incidence of testicular germ cell tumors are beginning to be observed in certain European populations. Additional data on predisposing factors related to race, estrogenic exposure, cryptorchidism, and infertility are becoming available. Significant work on the genetic and molecular alterations in tissue specimens and cell culture models of germ cell tumors continues. Additional treatment strategies for advanced stages of the disease are being evaluated. Cardiovascular and metabolic consequences of therapies in long-term testicular germ cell tumor survivors are being further clarified. Late relapses of successfully treated patients are also being increasingly recognized.

SUMMARY

More effective treatments for intermediate risk, poor risk, and recurrent germ cell tumors need to be developed, while long-term toxicities of therapies need to be further modified. Given these challenges, active research on these fronts continues and remains a priority.

Is full bilateral retroperitoneal lymph node dissection always necessary for postchemotherapy residual tumor?

BACKGROUND

Traditionally, postchemotherapy (PC) surgery for metastatic nonseminomatous germ cell tumor (NSGCT) has used a full bilateral retroperitoneal lymph node dissection (RPLND) from the crus of the diaphragm to the bifurcation of the common iliac arteries, from ureter to ureter. With the primary landing zone well defined in low-volume retroperitoneal disease, the authors performed modified dissections in the PC setting in a select population; and, herein, they report disease outcome.

METHODS

From 1991 to 2004, a retrospective review of the testicular cancer database at the authors' institution was performed to identify patients with NSGCT, normal serum tumor markers after cisplatin-based chemotherapy, and residual retroperitoneal tumor who underwent modified PC-RPLND. All patients had metastatic disease at initial presentation that was limited to the primary landing zone (left or right).

RESULTS

One hundred patients were identified, including 43 who underwent a right modified template, 18 patients who underwent a left full modified template, and 39 patients who underwent a left modified template. Pathology revealed cancer in 2% of patients, teratoma in 62% of patients, and necrosis in 36% of patients. The 2- and 5-year disease-free survival rate was 95%, and the median follow-up was 31.9 months (range, 1-152 months). Four patients developed recurrent disease with a median time to recurrence of 8.25 months (range, 6-11 months). All recurrences were outside the boundaries of a full bilateral RPLND.

CONCLUSIONS

Selected patients at PC surgery can be managed with modified PC-RPLND.