Role of the Urologist in Metastatic Testicular Cancer

Abstract

Testicular cancer is the quintessential disease for a multidisciplinary approach. Skilled radiologic assessment and pathologic diagnosis are necessary before initiation of any therapeutic strategy. Therapeutically, there are three excellent options for clinical stage I nonseminomatous disease: surveillance; retroperitoneal lymph node dissection (RPLND), usually nerve sparing; and primary chemotherapy. Stage II disease, with normal postorchiectomy tumor markers (serum human chorionic gonadotropin and alpha-fetoprotein) and a less than 3-cm maximal dimension of a nodal metastasis, is usually managed with RPLND. The cure rate for node-positive testis cancer with surgery alone is higher than with surgical treatment of nodal metastases from any other type of cancer. Other stage II, and all stage III, patients are treated initially withcisplatin-basedcombinationchemotherapy.Thereareclearly patients who would be incurable with chemotherapy or surgery alone, but who are cured with chemotherapy followed by RPLND or thoracotomy. The very experienced investigators from Memorial Sloan-Kettering Cancer Center (MSKCC; New York, NY) report on 210 such patients in this issue of the Journal of Clinical Oncology. 1 All patients received chemotherapy followed by postchemotherapyRPLNDforresectionofteratoma.Thisgroupof210 teratoma patients was obtained from a larger group of 532 men who underwent postchemotherapy (PC) RPLND at MSKCC from 1989 to 2003. The presence of teratoma in the orchiectomy specimen is a strong determinant of teratoma in a persistent PC retroperitoneal nodalmass.InaretrospectivereviewfromIndianaUniversityfrom 1987 to 2000, 644 patients were identified who had been treated with induction chemotherapy and PC RPLND. Three hundred seventy-five (58.2%) of 644 had teratomas in the orchiectomy specimen. Of those 375 patients, 321 (85.6%) had teratomas in the PC RPLND. In contrast, of the 269 patients without teratomas in the orchiectomy specimen, 130 patients (48%) had teratomas in the PC RPLND specimen. 2 One hundred eleven of these 375 patientshadPCretroperitonealmasses10cmorlargeronabdominal