Abstract
BackgroundRadiation therapy and systemic chemotherapy are recommended treatment options in marker-negative clinical stage (CS) IIA/B seminoma. Despite high cure rates of 82–94%, both therapeutic options are associated with significant long-term toxicities. ObjectiveTo evaluate the feasibility, oncological efficacy, and treatment-associated morbidity of primary nerve-sparing retroperitoneal lymph node dissection (nsRPLND) in CS IIA/B seminoma. Design, setting, and participantsA prospective, single-arm, clinical phase 2 trial including CS IIA/B seminoma patients was conducted. InterventionPrimary nerve-sparing retroperitoneal lymphadenectomy. Outcome measurements and statistical analysisRelapse-free and overall survival, surgery-associated complications according to the Clavien-Dindo classification, and Kaplan-Meier methods for survival calculation were assessed. Results and limitationsThirty patients at a mean age of 39.1 (34–52) yr with marker-negative CS IIA and IIB seminomas were recruited. The median follow-up was 22 (8–30) mo. Nineteen (63%) and 11 (36%) patients were diagnosed with stages IIA and B, respectively, at the time of primary diagnosis. Fourteen (47%) and 16 (53%) patients were diagnosed with CS IIA and IIB, respectively, at the time of nsRPLND. Twenty-seven and three patients underwent open and robot-assisted nsRPLND, respectively. The median operating room time was 125 (115–145) min, median blood loss was <150 ml, and median time of hospitalization was 4.5 (3–9) d. Four (13%) patients experienced Clavien-Dindo grade 3a complications. Lymph node histology revealed seminoma in 25 (80%) patients; two and three patients demonstrated embryonal carcinoma and benign disease, respectively. Sixteen patients underwent a serum analysis of miR371 preoperatively, which predicted metastatic disease in 12/13 and benign histology in 3/3 patients. Three of 30 (10%) patients developed an outfield relapse 4, 6, and 9 mo postoperatively and were salvaged by systemic chemotherapy. Limitations are the low patient number and length of follow-up. ConclusionsThe nsRPLND approach results in a high cure rate at midterm follow-up and is associated with a low frequency of treatment-associated morbidities, making this approach a feasible alternative to radiation therapy or systemic chemotherapy. Patient summaryThe standard treatment of clinical stage IIA/B seminomas is radiation therapy or chemotherapy, which results in a significantly increased frequency of long-term toxicity and secondary neoplasms. In this trial, we demonstrate that nerve-sparing retroperitoneal lymph node dissection is a feasible therapeutic approach with low morbidity and high oncological efficacy.
Published Version
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