Current Role of Retroperitoneal Lymph Node Dissection in Testicular Cancer

Progress in managing testicular cancer over the last 2 decades has producedsurvival rates of well over 90% using a multidisciplinary approach thatserves as a model for other tumors. Improved imaging techniques permitmore accurate clinical staging, allowing the clinician to select, for eachpatient, the sequence of surgical and chemotherapeutic modalities thatmaximizes survival while keeping morbidity within tolerable limits. Currentinvestigators are attempting to refine treatment protocols so as to maintainor improve survival while reducing morbidity and costs.

Surgical resection of the retroperitoneal lymph nodes has been an importanttool in managing testicular cancer for many years. In this excellent review,the authors describe the history, techniques, and rationale for the useof retroperitoneal lymph node dissection (RPLND). The effectiveness ofRPLND as primary or adjuvant therapy for low-stage disease or as an adjunctfor the resection of residual tumor following chemotherapy in advanceddisease represents a standard by which all other management approachesshould be measured. However, there is no consensus as to which patientsshould undergo RPLND or the most effective sequence of treatment modalities.

Role of RPLND in Low-Stage Disease

The majority of patients with clinical stage I testicular cancer havetumor confined to the testicle. A number of studies have shown that tumorrelapse develops in approximately one-quarter of patients managed by orchiectomyalone by 3 years (range, 20% to 40%) and in one-third by 4 years.[1] In80 stage I patients followed by surveillance for a mean of 83 months, relapseswere identified in 36.3%.[2]

Using current imaging techniques, accurate staging is possible for themajority of patients in whom additional treatment would be unnecessary.Even though RPLND is associated with low morbidity and mortality, subjectingall patients with stage I disease to this procedure in order to benefita minority is difficult to justify if accurate methods exist to stratifypatients for risk of relapse and effective salvage therapy is available.

Various pathologic factors have been associated with an increased riskof recurrence and, when one or more are present, relapses will be seenin 52% (range, 36% to 96%). As the authors point out, the absence of theserisk factors does not relieve the clinician of the responsibility to performcareful follow-up on a surveillance protocol, as relapses will be seenin 10% to 69% of patients without risk factors (mean, 22%).[1] Risk stratificationallows the clinician to offer RPLND to patients most likely to benefitfrom the procedure, while those with lower risk may benefit from a lessaggressive approach.

Surveillance as an Option

Surveillance requires that a patient be stable and willing to adhereto the more intense follow-up required. Although difficult to predict andmonitor, compliance has been studied in this population. In one study,compliance with scheduled clinical visits was less than 80% in 57% of patientswith stage I disease,[3] whereas the authors of another study found nomajor problems in management related to compliance.[4] In our own patientpopulation, compliance is well over 85%.

Surveillance has no physical impact on quality of life and does notappear to be associated with an excess of psychological disorders. In onegroup of 102 patients, stress due to disease-related anxiety was reportedto be minor in 46% of patients and a source of major distress in only 4%.[4]

When relapses occur, effective salvage therapy is available. Cisplatin(Platinol)-based chemotherapeutic protocols produce complete responsesin the majority of patients with retroperitoneal lymphadenopathy. Survivalrates of 80% to 96% are reported for bulky retroperitoneal disease andover 95% for smaller-volume tumors.[1,5,6]

When considering treatment, it is important to keep in mind that moststudies report retroperitoneal relapse alone in the minority of cases,while pulmonary recurrence, alone or in combination with retroperitonealdisease, or biochemical relapse is seen in 55%.[1] Although tumors at thesesites exhibit a more complete response to treatment than does retroperitonealdisease, they should not be regarded as of little importance.

Of interest, the authors report that only 5% of their stage I patientsexperienced an extraperitoneal relapse following RPLND. The authors areprobably correct in assuming that treatment success is greater when providedby clinicians with greater experience in dealing with this disease. Illustrativeof the effectiveness of salvage therapy is the reported survival rate of95% to 99% reported for patients with stage I testicular cancer who entersurveillance protocols.[2,4]

The overall costs associated with patient care for surveillance vs RPLNDappear to be identical.[7] More difficult to gauge are the costs to societyand the individual of the loss of productivity following surgical or chemotherapeuticinterventions.

Therefore, as the authors correctly point out, surveillance is a viableoption for a select group of patients without adverse histologic parameterswho are reasonably compliant. Patients who do not meet these criteria shouldbe advised to undergo RPLND. Using this approach, survival should be maintainedat a high rate, with morbidity minimized and costs stabilized.

Role of RPLND in Advanced-Stage Disease

Either RPLND or chemotherapy can be used as initial treatment of testicularcancer in the presence of detectable retroperitoneal disease. Both appearto be effective in eradicating smaller-volume disease. Reported relapserates following RPLND vary, and the role of adjuvant chemotherapy is controversial.In 174 patients with stage II disease treated initially by RPLND, no relapseswere seen in the 59 who received adjuvant chemotherapy, whereas the relapserate in untreated patients was 37%.[8]

If initial treatment is chemotherapy, a complete response requiringno adjuvant surgical intervention is seen in 40% to 71%.[6] Certain histologicparameters can be used to predict the failure of chemotherapy to producea complete response; these include teratomatous elements in the primarytumor and the presence of larger tumor masses.

Careful application of these two treatment modalities can produce similarsurvival results regardless of the sequence used. Finally, in selectedcases where tumor markers fail to normalize, excision of the residual retroperitonealmass may improve survival potential.[9]

Initial use of chemotherapy will eradicate disease in less than halfof patients with stage IIA-B disease, requiring adjuvant RPLND. Conversely,a substantial percentage of patients who initially undergo RPLND will experiencerelapse and require additional chemotherapy. Thus, therapy should be tailoredto individual circumstances. Some degree of patient selection can be employed,and each patient should be carefully counseled regarding treatment options.

References:

1. Lowe BA: Surveillance versus nerve-sparing retroperitoneal lymphadenectomyin stage I nonseminomatous germ-cell tumors. Urol Clin North Am 20:75-83,1996.

2. Ondrus D, Hornak M: Orchiectomy alone for clinical stage I nonseminomatousgerm cell tumors of the testis (NSGCTT): A minimum follow-up period of5 years. Tumori 80:362-364, 1994.

3. Young BJ, Bultz BD, Russell JA, et al: Compliance with follow-upof patients treated for non-seminomatous testicular cancer. Br J Cancer64:606-8, 1991.

4. Fossa SD, Jacobsen AB, Aass N, et al: How safe is surveillance inpatients with histologically low-risk non-seminomatous testicular cancerin a geographically extended country with limited computerised tomographicresources? Br J Cancer 70:1156-1160, 1994.

5. Horwich A, Stenning S: Initial chemother- apy for stage II testicularnon-seminoma. World J Urol 12:148-150, 1994.

6. Lerner ES, Mann BS, Blute ML, et al: Primary chemotherapy for clinicalstage II nonseminomatous germ cell testicular tumors: Selection criteriaand long-term results. Mayo Clin Proc 7:821-828, 1995.

7. Foster RS, Bihrle R, Little JS, et al: Stage II nonseminomatous germ-celltesticular tumors--the Indiana experience and risk-benefit analysis. WorldJ Urol 12:143-146, 1994.

8. Donohue JP, Thornhill JA, Foster RS, et al: The role of retroperitoneallymphadenectomy in clinical stage B testis cancer: The Indiana UniversityExperience. J Urol 153:8509, 1995.

9. Gerl A, Clemm C, Schmeller N, et al: Outcome analysis after post-chemotherapysurgery in patients with non-seminomatous germ cell tumors. Ann Oncol 6:483-488,1995.