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 After Chemotherapy

Standard Postchemotherapy RPLND

Patients who are clinically staged and found to have higher volume metastatic disease are managed with systemic chemotherapy. The rationale for this approach is that in patients who have retroperitoneal tumors greater than 10 cm in diameter, the chance for cure with surgical removal alone is less than 50%, and therefore systemic chemotherapy is reasonable.[3] Patients who have metastasis to the lungs or mediastinum in addition to retroperitoneal tumor are not cured with surgical therapy only, and systemic chemotherapy is appropriate in these circumstances as well.

Chemotherapy for so-called good-risk disease includes either three courses of BEP or four courses of etoposide and cisplatin.[3] In nonseminoma, good risk disease generally includes those patients with pulmonary visceral metastasis or nonmediastinal primaries, and those who do not have excessively high levels of serum AFP and beta hCG. Patients who are managed in this fashion will normalize serum tumor markers and experience the disappearance of all radiographic tumor approximately 70% of the time. The other 30% will experience normalization of serum markers but have persistent retroperitoneal, mediastinal, or pulmonary tumor (Fig 4).

Figure 4.

CT scan showing residual retroperitoneal tumor after chemotherapy at the level of the lower pole of the kidneys.

Patients who normalize serum markers but have persistent radiographic tumor undergo postchemotherapy surgery. This is usually a postchemotherapy RPLND since, in most cases, these patients have persistent tumor only in the retroperitoneum. The rationale for removing this residual tumor is threefold. First, an accurate determination of the histologic makeup of the tumor is quickly obtained, which in the case of persistent cancer allows the more expeditious administration of additional chemotherapy. Second, the surgical removal of residual teratoma is therapeutic. Removing residual teratoma is important since if not removed, teratoma can degenerate into other types of cancer that are generally chemoresistant. Residual unresected teratoma can grow and merely by its bulk can lead to intraperitoneal organ dysfunction. Third, in some cases, residual germ cell cancer remains, and the surgical removal of this cancer may be therapeutic.

After primary chemotherapy, if postchemotherapy RPLND is performed, the histologic findings of the mass generally will consist of necrosis 45% of the time, teratoma 45% of the time, and persistent germ cell cancer approximately 10% of the time.[18] The removal of teratoma or cancer may be therapeutic, while the removal of necrosis confers no therapeutic benefit to the patient. Many studies from around the world have attempted to accurately predict those patients who have only fibrosis and necrosis based on generally available clinical parameters.[19] Unfortunately, this predictability is not high enough to reliably exclude patients from postchemotherapy RPLND. Therefore, postchemotherapy RPLND is indicated in any patient who has residual radiographic tumor with normalization of serum markers after chemotherapy.

As noted previously, the morbidity of postchemotherapy RPLND is higher than the morbidity of primary RPLND. Acute postoperative problems include ileus, a higher probability of requiring concomitant nephrectomy or vena cavectomy, bleomycin-induced pulmonary problems, and a lower probability of maintaining emission and ejaculation. Some of these postchemotherapy procedures are technically demanding due to tumor bulk, the position of tumor relative to the great vessels, and the acknowledged desmoplastic reaction that may occur after metastatic tumor is treated with chemotherapy (Fig 5). The long-term survival after postchemotherapy RPLND is dependent on the pathology. Patients with only teratoma or necrosis and fibrosis do well long-term, while patients found to have persistent cancer are usually treated with two further courses of postoperative chemotherapy and experience a long-term disease-free status approximately 66% of the time.[3]

Figure 5.

Residual teratoma after chemotherapy in the upper left periaortic, retrocrural, and precaval.

Complicated Postchemotherapy RPLND

As previously discussed, the term "standard RPLND" applies to patients who have postchemotherapy RPLND after induction chemotherapy alone. The term "complicated postchemotherapy RPLND" applies to patients who have received more than induction chemotherapy only, have experienced retroperitoneal recurrence after primary RPLND, have failed all chemotherapy as indicated by elevated tumor markers but persistent retroperitoneal-only tumor, and have late relapse. Postchemotherapy surgery in this group of patients is technically demanding and is associated with a higher probability of requiring nephrectomy, colon resection, vena cavectomy, and/or aortic resection and replacement. However, even in these complicated patients, the morbidity is acceptable since some patients are cured with postchemotherapy surgery. Even in the two groups of patients with the most ominous pathologic findings (late relapse with yolk sac tumor and so-called desperation RPLND for chemoresistant cancer), the chance for cure with surgery alone is between 30% and 40%.[20] It is remarkable that these patients with documented chemoresistant metastatic cancer can be cured at this rate with the addition of surgical therapy alone.

Postchemotherapy Seminoma

Patients with higher volume retroperitoneal seminoma or widely metastatic seminoma are treated with cisplatin-based chemotherapy similar to patients with nonseminoma. Unlike patients with nonseminoma, however, teratoma is never associated with pure seminoma. Therefore, the issue of whether to resect postchemotherapy masses after chemotherapeutic treatment for pure seminoma is controversial. Generally, patients with residual masses after chemotherapeutic treatment of seminoma are managed expectantly, with only a small percentage of patients recurring in the area of the mass. Also, standard second-line chemotherapy in seminoma is curative at the 50% level, and most patients who experience growth of a postchemotherapy mass after induction chemotherapy are usually given second-line chemotherapy. Therefore, surgical resection is reserved for patients who fail second-line chemotherapy and have a localized mass. Alternatively, some centers advocate surgical resection of postchemotherapy masses in pure seminoma if the mass is greater than 3 cm in diameter.[21] This issue of whether to resect postchemotherapy masses in seminoma remains controversial, and management should be individualized. The use of positron emission tomography scanning in this situation is also controversial.

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