Current Status of Retroperitoneal Lymph Node Dissection and Testicular Cancer: When to Operate

Richard Foster, MD; Richard Bihrle, MD

Disclosures

Cancer Control. 2002;9(4) 

In This Article

RPLND in Low-Stage Disease

Clinical Stage I

After radical inguinal orchiectomy for a solid intratesticular mass, the patient undergoes a staging workup that includes determination of serum alpha fetoprotein (AFP), beta human chorionic gonadotropin (hCG), and computed tomography (CT) scans of the abdomen, pelvis, and chest. If the CT scans are normal and the markers normalize after radical inguinal orchiectomy or, alternatively, are falling appropriately based on the half-life of AFP of 4 1/2 days and beta hCG of 1 1/2 days, the patient is classified as having clinical stage I disease.[3] Approximately 30% of patients who are clinical stage I, in fact, have occult metastatic disease.[4] Patients in this circumstance are managed by either surveillance or nerve-sparing RPLND. No prospective randomized trial has compared these two methods of management, but many series of RPLND and surveillance from around the world have shown that the chance for cure is essentially the same with either method of management and is approximately 99%.[5,6]

The surveillance scheme employs a careful paradigm of follow-up using chest radiographs, physical examinations, marker determinations, and CT scans in order to diagnose those patients with metastatic disease early when the tumor burden is low. Patients who are found to have growing metastatic tumor are then managed with cisplatin-based chemotherapy, with approximately one third of patients who are treated with chemotherapy requiring subsequent postchemotherapy RPLND.[7] The major advantage of a surveillance approach is that patients who have no metastatic disease undergo no therapy, and patients diagnosed with metastatic tumor are treated appropriately with cisplatin-based chemotherapy. Disadvantages of the surveillance scheme include the psychological burden on the patient, the higher probability of receiving chemotherapy compared to management with RPLND, and a higher probability of patients requiring postchemotherapy RPLND, a procedure with higher morbidity than primary RPLND.[8]

The advantages of managing a patient with clinical stage I nonseminoma with nerve-sparing RPLND include the immediate determination of whether metastatic retroperitoneal tumor exists, the chance for cure with surgical removal of involved lymph nodes of 50% to 75% (depending on the volume of metastasis), and the elimination of the need for monitoring a patient postoperatively with CT scans. Additionally, the initial follow-up after RPLND is only 2 years, whereas the follow-up requirement after surveillance is at least 5 years.

As surgical therapy for metastatic testicular cancer has evolved, the full bilateral RPLND used in the past evolved first to a template-type dissection and then to a nerve-sparing modification with a unilateral template (Fig 1). The evolution of this procedure has resulted in low acute and long-term morbidity.[9,10]

Figure 1.

The templates of dissection for a right-sided (A) and left-sided (B) testicular primary. Reprinted with permission from the Indiana University Office of Visual Media.

For patients with a right-sided testicular primary, right modified nerve-sparing RPLND is performed by first dissecting the efferent sympathetic fibers that control emission and ejaculation, followed by a template removal of lymphatic tissue in the right paracaval, precaval, and interaortocaval areas (Fig 2). This removal of lymphatic tissue is an en bloc removal and not a "node plucking" removal of involved lymph nodes. Careful removal of involved lymph nodes is important since testis cancer has the capability of implanting intraperitoneally if tumor is spilled at the time of the procedure.

Figure 2.

The anatomy of retroperitoneal sympathetics shown in relation to the aorta and vena cava. Reprinted with permission from the Indiana University Office of Visual Media.

For patients with a left-sided primary, left modified nerve-sparing RPLND is performed by first dissecting efferent sympathetic fibers from the left side of the retroperitoneum, followed by en bloc removal of lymphatic tissue in the left para-aortic and pre-aortic areas.

The modified nerve-sparing RPLND is performed through a midline incision. At our institute, the current operative time is approximately 2 hours and the hospitalization is about 3 1/2 days. Transfusions are not necessary, and the long-term morbidity includes a 1% to 2% chance of a small bowel obstruction due to adhesions and a less than 5% chance of an incisional hernia. Return to full physical activity is possible in 3 to 6 weeks.

The chance for cure with removal of involved lymph nodes is 50% to 75%.[4,11] Patients with minimal microscopic spread to the retroperitoneum are cured at the 75% level; those with more significant involvement experience surgical cure approximately 50% of the time. Patients who recur after RPLND are usually found to have either serologic recurrence with elevation of hCG or AFP, or documentation of chest metastasis on chest radiograph. These patients are curable at the 99% level with three courses of bleomycin, etoposide, and cisplatin (BEP) or four courses of etoposide and cisplatin.[12] An option for patients who undergo modified nerve-sparing RPLND and are found to have metastatic retroperitoneal nodes is to administer two courses of BEP postoperatively as an adjuvant.[13] This lowers the chance of recurrence after RPLND to less than 1%. This approach was developed in the late 1970s and 1980s to avoid administering the third and fourth courses of chemotherapy. During that era, the morbidity of chemotherapy was significantly greater, with many patients experiencing severe problems with nausea, vomiting, and granulocytopenia. Therefore, avoiding the third and fourth course of chemotherapy was desirable to reduce the morbidity of therapy. Currently, however, with the availability of better antiemetics and growth factors, the current three courses of chemotherapy are not associated with as high a morbidity as in former times. Therefore, the rationale for adjuvant chemotherapy in patients found to have retroperitoneal metastasis is not as strong. Currently, patients who are found to have retroperitoneal metastasis are given the choice of close follow-up or two courses of adjuvant BEP. The choice is dependent on the patient's opinion about receiving or avoiding chemotherapy. A discussion of the possible acute and long-term side effects of chemotherapy with the patient is imperative in this situation. Psychological issues are also important in this process.

Patients with clinical stage I nonseminoma who choose nerve-sparing RPLND as a method of management usually cite fertility issues as one reason for their choice. Systemic chemotherapy can affect spermatogenesis in the contralateral testis, and since nerve-sparing preserves emission and ejaculation, some patients will opt for surgical therapy in an effort to avoid chemotherapy.[14] Also, testis cancer chemotherapy has been associated with long-term side effects, and patients may want to avoid chemotherapy for these reasons also.[15] Psychological issues are important as some patients find it difficult to have a good quality of life on a surveillance scheme while worrying about disease recurrence. Finally, the follow-up after nerve-sparing RPLND does not involve CT scans, and some patients will choose surgical therapy in an effort to avoid such intense and prolonged follow-up.

Clinical Stage II

Patients who have nonseminomatous testis cancer and have evidence of retroperitoneal metastasis on CT scanning are classified as having clinical stage II disease. Similar to clinical stage I disease, two methods of management are available, each yielding a chance for cure of greater than 95%. The first approach is to administer systemic cisplatin-based chemotherapy, with approximately one third of such patients requiring RPLND after chemotherapy. The second approach is to perform a primary RPLND to remove metastatic nodes in the retroperitoneum, with approximately one third of patients requiring chemotherapy after primary RPLND due to systemic recurrence.[11]

The advantage of treating clinical stage II patients with primary chemotherapy is that some will experience a clinical complete remission and thereby avoid any surgical therapy. All such patients, however, receive three or four courses of chemotherapy and are exposed to the potential side effects of the therapy. In testis cancer, there is the potential for clinical overstaging; 15% to 23% of patients who are believed to have retroperitoneal tumor on CT scanning in fact have no metastatic tumor to the retroperitoneum if managed by RPLND.[11] If all such patients are managed with primary chemotherapy, some will receive chemotherapy that they do not require. Another disadvantage of managing patients with primary chemotherapy is that one third of such patients will require postchemotherapy RPLND, usually for teratomatous elements in the retroperitoneum. Teratoma is not sensitive to chemotherapy and requires surgical removal. As mentioned previously, postchemotherapy RPLND has higher acute morbidity than does primary RPLND. Similarly, nerve-sparing is not as appropriate or technically possible in postchemotherapy RPLND compared to primary RPLND. Therefore, postchemotherapy RPLND is associated with a higher probability of loss of emission and ejaculation.

Patients with clinical stage II nonseminoma who are managed with primary RPLND usually undergo full bilateral RPLND instead of a template-type dissection. The rationale for this is that previous studies have shown that with increasing volumes of retroperitoneal metastasis, the probability of having disease bilaterally in the retroperitoneum is higher. The chance for a surgical cure in these patients ranges from 50% to 75%, depending on the amount of retroperitoneal spread.[4,11] In most clinical stage II patients, nerve-sparing is possible and thus preservation of emission and ejaculation is possible (Fig 3). After RPLND for stage II disease, patients are followed with physical examination, chest radiograph, and determination of serum tumor markers in order to diagnose recurrence. As noted, approximately one third of patients who are treated with RPLND for clinical stage II nonseminoma will experience a recurrence. These recurrences are usually pulmonary or detected by rising serum AFP or beta hCG. Virtually all of these patients with recurrence are curable with three courses of BEP.

Figure 3.

Intraoperative photo of full bilateral RPLND with bilateral preservation of sympathetic fibers.

Similar to clinical stage I patients who are found to be pathologic stage II, clinical stage II patients may be offered two adjuvant courses of BEP after RPLND. Again, this approach virtually eliminates the probability of recurrence and therefore is reasonable in selected patients. However, there is no requirement for administering two courses of BEP after RPLND for stage II disease since, as noted above, 50% to 75% of patients are cured by surgical therapy alone.

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