Low-stage Nonseminomatous Germ Cell Research Articles

Primary robotic RLPND for nonseminomatous germ cell testicular cancer: a two-center analysis of intermediate oncologic and safety outcomes.

To evaluate the intermediate-term oncologic outcomes and safety profile of the largest case series of primary robotic retroperitoneal lymphadenectomy for low-clinical-stage non-seminomatous germ cell testicular cancer. This was a two-center retrospective analysis of robotic RPLND cases for low-clinical-stage (stage I-IIB) non-seminomatous germ cell testicular cancer in the primary setting. Demographic, perioperative, operative and oncologic variables were collected between March 2008 and May 2019. Descriptive analyses were performed and presented as medians with interquartile ranges for continuous variables and frequency and proportions for categorical variables. A survival analysis of time to recurrence was performed using Cox proportional hazards model. Using logistic regression, risk factors for complications were analyzed. Both univariate and multivariate analyses were performed. A total of 58 patients (CS 1 = 56, CS IIA = 2, CS IIB = 0) were identified. The median follow-up was 47months and the 2-year recurrence-free survival rate was 91%. The five recurrences were all out of the performed dissection template (pelvis = 1 and lung = 4). Only five patients (29%) with occult metastasis underwent adjuvant chemotherapy. The median operative time was 319min [interquartile range (IQR) 276-355min], estimated blood loss was 100ml (IQR 75-200ml), node count was 26 (IQR 20-31), and length of stay 2 d (IQR 1-3days). There were 2 (3.3%) intraoperative complications, 19 (32.7%) 30-day postoperative complications to include 14 (24.1%) Clavien grade I, 4 (6.9%) Clavien grade II, 1 (1.7%) Clavien grade III and 0 Clavien grade IV complications. No statistical significance was found on multivariate or univariate analysis for survival analysis of time to recurrence and risk factors for complications. This study represents the largest case series of primary R-RPLND for the treatment of low-stage non-seminomatous germ cell tumors (NSGCT). With 47months of follow-up and a low rate of adjuvant chemotherapy, intermediate oncologic efficacy appears to be comparable to the gold standard open approach.

Safety and Early Oncologic Effectiveness of Primary Robotic Retroperitoneal Lymph Node Dissection for Nonseminomatous Germ Cell Testicular Cancer

BackgroundPrimary robot-assisted retroperitoneal lymph node dissection (R-RPLND) has been studied as an alternative to open RPLND in single-institution series for patients with low-stage nonseminomatous germ cell tumors (NSGCT). ObjectiveTo evaluate a multicenter series of primary R-RPLND for low-stage NSGCT. Design, setting, and participantsBetween 2011 and 2015, 47 patients underwent primary R-RPLND at four centers for Clinical Stage (CS) I-IIA NSGCT. Surgical procedureR-RPLND was performed using the da Vinci surgical system (Intuitive Surgical Inc., Sunnyvale, CA, USA). Outcome measurements and statistical analysisData were collected regarding patient demographics, primary tumor characteristics, pathologic findings, and clinical outcomes. Results and limitationsForty-two patients (89%) were CS I and five (11%) were CS IIA. The median operative time was 235min (interquartile range [IQR]: 214–258min), estimated blood loss was 50ml (IQR: 50–100ml), node count was 26 (IQR: 18–32), and length of stay was 1 d. There were two intraoperative complications (4%), four early postoperative complications (9%), no late complications, and the rate of antegrade ejaculation was 100%. Of the eight patients (17%) with positive nodes (seven pN1and one pN2), five (62%) received adjuvant chemotherapy. The one recurrence was out of template in the pelvis after adjuvant chemotherapy (resected teratoma). The median follow-up was 16 mo and the 2-yr recurrence-free survival rate was 97% (95% confidence interval: 82–100%). Limitations include retrospective design and limited follow-up. ConclusionsOur multicenter experience supports R-RPLND as a potential option at experienced centers in select patients with low-stage NSGCT. Informal comparison to open and laparoscopic series suggests R-RPLND has an acceptably low morbidity profile, but oncologic efficacy evaluation requires further evaluation. Patient summaryWe examined outcomes after robot-assisted retroperitoneal lymph node dissection for patients with low-stage nonseminomatous testicular cancer with our data suggesting the robotic approach has acceptable morbidity and early oncologic outcomes.

MP23-10 MULTICENTER EVALUATION OF PRIMARY ROBOT-ASSISTED LAPAROSCOPIC RPLND IN LOW-STAGE NON-SEMINOMATOUS TESTICULAR CANCER

INTRODUCTION AND OBJECTIVES: Robot-assisted laparoscopic retroperitoneal lymph node dissection (R-RPLND) has been examined in attempt to minimize treatment-related morbidity for patients with low-stage non-seminomatous germ cell tumors (NSGCT). While robot-assistance may allow surgeons to better replicate open techniques, it remains unclear if R-RPLND offers comparable outcomes to open RPLND. This study evaluates a multicenter series of primary robot-assisted laparoscopic retroperitoneal lymph node dissection (RRPLND) for NSGCT. METHODS: Between 2008-2015, 60 patients underwent primary R-RPLND at five centers for CS I-IIA NSGCT. Data were collected regarding patient demographics, primary tumor characteristics, perioperative information, pathologic findings, and clinical outcomes. RESULTS: Among all study participants, 51 (85%) were CS I and 9 (15%) were CS IIA. Median operative time was 239 minutes (IQR: 217-271 min), estimated blood loss was 50 mL (IQR: 50-100 mL), node count was 24 (IQR: 17-31), and median length of stay was 1 day. There were 2 intraoperative complications (3%) including 1 open conversion (2%), and 6 early post-operative complications (10%). No late complications were observed and the rate of antegrade ejaculation was 96%. Of the 12 patients (20%) with positive nodes (10 pN1and 2 pN2), 6 (50%) received adjuvant chemotherapy. There was 1 out-of template recurrence (2%) in the pelvis after adjuvant chemotherapy, which was resected (teratoma). There have been no retroperitoneal or systemic recurrences. Median follow-up was 18 months and the 2-year recurrence-free survival rate was 98% (95% CI: 87% to 100%) including a 100% 2-year recurrence-free survival rate among patients with pN+ disease without adjuvant chemotherapy (n1⁄46) at a median of 26 months follow-up. CONCLUSIONS: Our multicenter experience supports RRPLND as a potential option at experienced centers in select patients with low-stage NSGCT. Informal comparison to open and laparoscopic series suggests R-RPLND has an acceptably low morbidity profile, but oncologic efficacy evaluation requires further evaluation.

The management of low-stage non-seminomatous germ cell tumors

The prognosis of patients with stage I non-seminomatous germ cell tumors is in general very good. However, a large number of patients relapse with metastatic disease after orchidectomy Therefore, adjuvant treatment, in the form of either chemotherapy or retroperitoneal dissection is recommended, although active surveillance has been found to be as good a way of treating these patients with overall excellent results.

The management of low-stage non-seminomatous germ cell tumors

The prognosis of patients with stage I non-seminomatous germ cell tumors is in general very good. However, a large number of patients relapse with metastatic disease after orchidectomy Therefore, adjuvant treatment, in the form of either chemotherapy or retroperitoneal dissection is recommended, although active surveillance has been found to be as good a way of treating these patients with overall excellent results.

Management of Low-stage Nonseminomatous Germ Cell Tumors of Testis: SIU/ICUD Consensus Meeting on Germ Cell Tumors (GCT), Shanghai 2009

To advise urologists and other clinicians on the appropriate management of low-stage (clinical Stage [CS] I, IS, IIA, and IIB) nonseminomatous germ cell tumors of the testis. A panel was convened of experts from 5 countries. A literature search in MEDLINE was used to identify evidence from relevant studies on the outcome and toxicity of observational, surgical, and chemotherapeutic approaches for low-stage nonseminomatous germ cell tumors to form the basis of the panel's recommendations. The panel has recommended the treatment of nonseminomatous germ cell tumors in centers with medical, surgical, and diagnostic expertise in testicular cancer. The cancer-specific survival rate for CS I and CS IIA-IIB should approach 100% and 95%-100%, respectively. Patients with CS I should be made aware of all treatments (ie, surveillance, primary chemotherapy, and retroperitoneal lymph node dissection) and the potential side effects. For patients with CS I at low risk of occult metastasis, surveillance is preferred. For patients at high risk of occult metastasis, all 3 options can be considered. For immediate treatment, the choice between primary chemotherapy and retroperitoneal lymph node dissection should be determined by patient preference and the specific expertise of the treating institution. Patients with increasing postorchiectomy serum α-fetoprotein or human choriogonadotropin levels (CS IS and CS IIA-IIB) should receive induction chemotherapy. Induction chemotherapy or retroperitoneal lymph node dissection can be considered for patients with CS IIA-IIB with normal postorchiectomy α-fetoprotein and human choriogonadotropin levels. Surveillance can be considered for patients with equivocal computed tomography retroperitoneal findings who are otherwise at low risk of metastatic disease. These clinical practice guidelines are designed to improve clinical practice from the available evidence and the expert opinion of the panel. As such, deviation from these recommendations should be based on sound clinical judgment, considering the unique situation of the patient and the expertise of the treating physician and institution.

Laparoscopic Retroperitoneal Lymph Node Dissection for Stage I Nonseminomatous Germ Cell Testis Tumors: The First Case Series in Iran

To report laparoscopic retroperitoneal lymph node dissection (RPLND) as an approach for management of low-stage nonseminomatous germ cell testis tumors (NSGCT). Between August 2002 and December 2008, 19 patients with stage I NSGCT underwent RPLND in our center. Mean operation time was 340 minutes (range, 250 to 360 minutes). Procedure in 2 (10.5%) patients was converted to open. Four (21%) patients had tumors with pure histopathology while other 15 (79%) had mixed histopathology. The mean number of removed lymph nodes was 11 (range, 6 to 14). Pathology revealed lymph node involvement in 8 (42%) patients, including 6 (75%) viable tumors and 2 (25%) teratoma. After on average 47-month follow-up (range, 3 to 70 months), recurrence occurred in 2 (10.5%) patients, who underwent open retroperitoneal lymph node dissection after chemotherapy, and surgical pathology revealed teratoma in one and fibrotic tissue in another. No patient developed systematic metastasis during followup period. Our results show that compared with open surgery, RPLND has same oncologic outcome, but lower, and can be recommended for management of patients with low stage NSGCT.

Surgical management of low‐stage nonseminomatous germ cell testicular cancer

The optimal treatment of low-stage nonseminomatous germ cell testicular cancer (NSGCT) is controversial. For clinical stage (CS) I NSGCT, retroperitoneal lymph node dissection (RPLND), two cycles of chemotherapy and surveillance are all accepted treatment options. For CS IIA-B, standard treatments include RPLND (+/- adjuvant chemotherapy) and induction chemotherapy (+/- RPLND). The long-term survival rate is >97% for CS I and 95% for CS IIA-B NSGCT, regardless of the treatment received. The risk of retroperitoneal metastasis varies by clinical stage (25-35% for CS I, 65-85% for CS IIA-B), and the presence of lymphovascular invasion and percentage of embryonal carcinoma in the primary tumour. Patients with elevated serum tumour markers (STMs) and adenopathy of >3 cm are at high risk of having occult systemic disease. Compared with chemotherapy, RPLND is associated with a considerably more favourable long-term morbidity profile and is the most effective method for controlling the retroperitoneum. Surveillance is associated with the lowest risk of long-term complications. As such, we favour surveillance for low-risk CS I, induction chemotherapy for those at high risk of systemic disease (elevated STM, adenopathy >3 cm), and RPLND for all others. Modified template dissections reduce the risk of ejaculatory dysfunction, but might increase the risk of local recurrence. Therefore, we favour a full-bilateral template dissection with nerve-sparing in patients with low-stage NSGCT. The therapeutic efficacy of laparoscopic RPLND is not proven and currently should be considered a staging procedure only. Adjuvant chemotherapy after RPLND is typically restricted to patients with pathological stage N2-3 disease.

Incidence of Disease Outside Modified Retroperitoneal Lymph Node Dissection Templates in Clinical Stage I or IIA Nonseminomatous Germ Cell Testicular Cancer

We evaluated the incidence, sites and histology of disease outside 5 modified retroperitoneal lymph node dissection templates for patients with low stage nonseminomatous germ cell tumors of the testis. Our cohort consisted of 500 consecutive patients with clinical stage I to IIA nonseminomatous germ cell tumors who underwent primary retroperitoneal lymph node dissection from 1989 to 2004. We analyzed 191 patients with pathological stage II disease and defined the incidence of disease outside 5 modified retroperitoneal lymph node dissection templates, 3 described for open surgery (Testicular Tumor Study Group, Indiana University and Memorial Sloan-Kettering Cancer Center) and 2 for laparoscopic surgery (University of Innsbruck and The Johns Hopkins University). Of 191 patients with pathological stage II disease, 111 (58%) had clinical stage I disease and 80 (42%) had clinical stage IIA disease. Depending on the template applied, extra-template disease ranged from 3% to 23% of all patients and was 1% to 11% of patients with pN1 disease. Regardless of template, histological distribution of extra-template disease was not significantly different from in-template disease with approximately 90% viable germ cell tumor, 10% teratoma only and 20% with any teratoma. For right side templates inclusion of para-aortic, preaortic and right common iliac regions decreased the incidence of extra-template disease to 2%. For left side templates inclusion of interaortocaval, precaval, paracaval and left common iliac regions decreased the incidence of extra-template disease to 3%. A significant number of men with clinical stage I to IIA nonseminomatous germ cell tumors and retroperitoneal metastases have disease present outside the limits of modified templates, including 20% to 30% with chemoresistant teratomatous elements. The data suggest that more extensive nerve sparing templates optimize oncological efficacy and ejaculation preservation, and minimize overall treatment morbidity.

Ejaculatory function in stage T1 nonseminomatous germ cell tumors: retroperitoneal lymph node dissection versus surveillance--a decision analysis.

Ejaculatory function remains a major concern for patients with low stage nonseminomatous germ cell tumors of the testis. Whereas, it has been extensively studied in patients undergoing retroperitoneal lymph node dissection, preservation of ejaculatory function on surveillance protocols has not been studied. To compare ejaculatory function for surveillance protocols to primary retroperitoneal lymph node dissection appropriately, we constructed a decision analysis model mimicking the standard treatment algorithm for stage 1 nonseminomatous germ cell tumor of the testis. The primary clinical payoff for this study is ejaculatory function. Based on this model, we established that a primary nerve sparing retroperitoneal dissection must be performed with a 96.8% ejaculatory function rate to be recommended as the appropriate therapy. However, if a highly skilled surgeon routinely performs post-chemotherapy dissection with an ejaculatory function rate of 69.2% or greater, surveillance should be offered as the primary treatment modality. This result simply demonstrates a high skill level to allow the surgeon to salvage ejaculatory function in post-chemotherapy retroperitoneal lymph node dissection settings. If this level cannot be achieved, primary retroperitoneal lymph node dissection is the best choice. If we account for a 10% loss of ejaculatory function from primary chemotherapy, the minimum ejaculatory function rate for primary retroperitoneal dissection decreases to 95.7%. In the post-chemotherapy setting an 85.7% ejaculatory function rate must be achieved for surveillance to be considered the optimal choice. Clearly, less surgical rigor is needed with a primary retroperitoneal lymph node dissection when correcting for the effects of chemotherapy on ejaculatory function. Despite this fact, 1-way sensitivity analysis revealed that our model is insensitive to the ejaculatory function effects of chemotherapy. Furthermore, if the likelihood of recurrence on surveillance is greater than 16%, primary nerve sparing retroperitoneal lymph node dissection should again be recommended. Thus, to maximize ejaculatory function for patients with stage 1 nonseminomatous germ cell tumor a nerve sparing primary retroperitoneal lymph node dissection should always be performed, unless the likelihood of recurrence on surveillance is low or the surgical skill level allows for a highly successful post chemotherapy nerve sparing dissection.

Management of patients with low-stage nonseminomatous germ cell testicular cancer

Management options for patients with clinical stage (CS) I nonseminomatous germ cell testicular cancer (NSGCT) include surveillance, retroperitoneal lymph node dissection (RPLND), or two cycles of bleomycin-etoposide-cisplatin (BEP x 2) chemotherapy. The optimal management of these patients is controversial, as cure rates of 97% or greater are reported with each of these treatment modalities. Patients without evidence of lymphovascular invasion, a predominant component of embryonal carcinoma, or advanced pathologic (p) T stage (pT 2 or greater) are at low risk for occult metastases and are optimal candidates for surveillance. Compliance with diagnostic testing and imaging is essential for a successful surveillance strategy to detect and treat metastases at an early stage. For patients who are not candidates for surveillance, RPLND offers several advantages over chemotherapy. RPLND alone is curative in 50% to 80% of CS I patients with pathologic stage (PS) II, and an estimated 75% of CS I patients avoid chemotherapy (as adjuvant therapy or for treatment of relapse). Virtually all patients are cured following two cycles of adjuvant chemotherapy for PS II disease, which is reserved for patients with high-volume (PN2-3) retroperitoneal disease. The poor outcome of patients with late retroperitoneal recurrence from unresected, chemorefractory germ cell testicular cancer indicates that RPLND is a vital component to the long-term cure of patients with NSGCT. Approximately 20% to 30% of patients with PS II disease have retroperitoneal teratoma (which is chemoresistant), and an estimated 5% of PS II patients have chemoresistant viable cancer following BEP x 2 as primary therapy. When RPLND is omitted, these patients are at risk for late recurrence with potentially lethal consequences. Patients who relapse after RPLND are "chemotherapy-naïve" and cured in virtually all cases with good-risk chemotherapy regimens. When nerve-sparing techniques are employed to preserve ejaculation, RPLND is also associated with a more favorable long-term toxicity profile compared with chemotherapy. In the absence of conclusive evidence from a randomized trial, we believe RPLND is the treatment of choice for patients with CS I NSGCT who are not candidates for surveillance, as it offers the greatest likelihood of long-term cure with considerably less morbidity than primary chemotherapy.

Retroperitoneal lymph node dissection in the treatment of low-stage nonseminomatous germ cell tumors of the testicle: An update

Nonseminomatous germ cell tumors (NSGCT) of the testicle are highly treatable and curable. The evolution of cancer control for this disease has shown an effective integration of medical and surgical approaches over the last 3 decades. Current emphasis in the therapy of NSGCT focuses on minimizing treatment-related morbidity while maintaining consistently high cure rates as previously seen. Retroperitoneal lymph node dissection (RPLND) in experienced hands is a critical component of the treatment armamentarium in this disease. RPLND is an accurate staging tool providing important information to determine the need for chemotherapy. When performed properly, RPLND eliminates the retroperitoneum as a site for relapse, which in turn provides emotional and psychological relief to the patient, and simplifies the follow-up protocol. RPLND alone can also provide high cure rates in patients with low clinical stage disease and high risk factors, such as lymphovascular invasion or predominance of embryonal histology in the primary tumor. Teratoma is chemoresistant and, when present in the primary tumor of patients with low stage, may be best treated with primary RPLND. Primary chemotherapy in the treatment of low stage NSGCT deserves continual investigation as long-term toxicities become more apparent. Observation is an option for the highly motivated patient but requires a rigorous follow-up schedule to avoid relapse. Laparoscopic RPLND is a viable staging tool; however, oncologic control of the retroperitoneum has not been reliably determined.

Retroperitoneal lymph node dissection in the treatment of low-stage nonseminomatous germ cell tumors of the testicle

Nonseminomatous germ cell tumors of the testicle are highly treatable and curable. The evolution of cancer control for this disease has demonstrated an effective integration of medical and surgical approaches over the last 30 years. Current emphasis in the therapy of nonseminomatous germ cell tumors focuses on minimizing treatment-related morbidity while maintaining consistently high cure rates. Retroperitoneal lymph node dissection in experienced hands is a critical component of the treatment armamentarium in this disease. Retroperitoneal lymph node dissection is an accurate staging tool that provides important information in determining the need for chemotherapy. When performed properly, retroperitoneal lymph node dissection eliminates the retroperitoneum as a site for relapse, which in turn provides emotional and psychological relief to the patient and simplifies the follow-up protocol. Retroperitoneal lymph node dissection alone can also provide high cure rates in patients with clinical low-stage disease and high-risk factors such as lymphovascular invasion or predominance of embryonal histology in the primary tumor. Teratoma is known to be chemoresistant and, when present in the primary tumor of low-stage patients, may be best treated with primary retroperitoneal lymph node dissection. Primary chemotherapy in the treatment of low-stage nonseminomatous germ cell tumors deserves continual investigation as long-term toxicities become more apparent. Observation is an option for the highly motivated patient, but requires a rigorous follow-up schedule to avoid relapse. Laparoscopic retroperitoneal lymph node dissection is a viable staging tool, however, oncologic control of the retroperitoneum has not been reliably determined.

The management of nonseminomatous testicular cancer.

Despite the fact that testis cancer accounts for only 1% of all male malignancies, it is the most common solid malignancy affecting males between the ages of 15 to 35 years. The management of germ cell tumors (GCT) of the testis has proved to be a model of success among solid tumors. This is due to tremendous advances during the past 2 decades, which have changed the once dismal prognosis for patients with advanced disease. Testicular cancer has, in fact, become one of the most curable of all solid neoplasms. Thirty years ago testicular cancer accounted for 11.4% of all cancer deaths in the 25 to 34 year age group, with an overall 5 year survival rate of 64%. The most recent five-year survival rate for GCT of the testis in the United States was recently reported as being in excess of 90%. Improved prospects for cure and long-term disease free survival rate, are related to a better understanding of the natural history of testicular tumors, improved staging methods and surgical techniques, as well as to the introduction of effective platinum based combination chemotherapy. Modifications to the surgical management of testis cancer have significantly reduced morbidity associated with the classical full bilateral retroperitoneal lymph node dissection. Template and nerve sparing retroperitoneal node dissections are now routinely employed in low stage nonseminomatous germ cell tumors (NSGCT), providing the patient with the benefit of accurate pathological staging combined with reduced morbidity. In addition, nerve sparing techniques have also been used in dissections for residual disease following chemotherapy. Chemotherapy for advanced GCT has undergone a number of important breakthroughs during the past three decades. In the 1960's the first major chemotherapeutic advance in metastatic NSGCT was described; a combination of chlorambucil, methotrexate and dactinomycin produced a response rate of 30%. By the 1970's combination therapies such as vinblastine and bleomycin had been shown to produce objective responses; 57% complete response rates and 45% long-term disease-free survival rates were reported. The discovery of cisplatin as a highly effective anti-neoplastic agent in 1965, and its later use in germ cell tumors of the testis (GCT), was another important breakthrough. In 1974 the combination of cisplatin, vinblastine and bleomycin was investigated by the Indiana group. Of the 47 patients in the initial phase II study, 100% achieved a response rate. Thirty five (74%) patients achieved complete remission, the remaining patients achieved a partial remission.

Ejaculatory Function in Stage T1 Nonseminomatous Germ Cell Tumors: Retroperitoneal Lymph Node Dissection Versus Surveillance—A Decision Analysis

Ejaculatory function remains a major concern for patients with low stage nonseminomatous germ cell tumors of the testis. Whereas, it has been extensively studied in patients undergoing retroperitoneal lymph node dissection, preservation of ejaculatory function on surveillance protocols has not been studied. To compare ejaculatory function for surveillance protocols to primary retroperitoneal lymph node dissection appropriately, we constructed a decision analysis model mimicking the standard treatment algorithm for stage 1 nonseminomatous germ cell tumor of the testis. The primary clinical payoff for this study is ejaculatory function. Based on this model, we established that a primary nerve sparing retroperitoneal dissection must be performed with a 96.8% ejaculatory function rate to be recommended as the appropriate therapy. However, if a highly skilled surgeon routinely performs post-chemotherapy dissection with an ejaculatory function rate of 69.2% or greater, surveillance should be offered as the primary treatment modality. This result simply demonstrates a high skill level to allow the surgeon to salvage ejaculatory function in post-chemotherapy retroperitoneal lymph node dissection settings. If this level cannot be achieved, primary retroperitoneal lymph node dissection is the best choice. If we account for a 10% loss of ejaculatory function from primary chemotherapy, the minimum ejaculatory function rate for primary retroperitoneal dissection decreases to 95.7%. In the post-chemotherapy setting an 85.7% ejaculatory function rate must be achieved for surveillance to be considered the optimal choice. Clearly, less surgical rigor is needed with a primary retroperitoneal lymph node dissection when correcting for the effects of chemotherapy on ejaculatory function. Despite this fact, 1-way sensitivity analysis revealed that our model is insensitive to the ejaculatory function effects of chemotherapy. Furthermore, if the likelihood of recurrence on surveillance is greater than 16%, primary nerve sparing retroperitoneal lymph node dissection should again be recommended. Thus, to maximize ejaculatory function for patients with stage 1 nonseminomatous germ cell tumor a nerve sparing primary retroperitoneal lymph node dissection should always be performed, unless the likelihood of recurrence on surveillance is low or the surgical skill level allows for a highly successful post chemotherapy nerve sparing dissection.

Management of low-stage nonseminomatous germ cell tumors of the testis.

Testicular cancer has become one of the most curable of all solid neoplasms. High cure rates associated with modern treatment regimens for low-stage testis cancer have resulted in a shift in focus toward reducing morbidity of potentially toxic treatment regimens.

Retroperitoneal recurrences after retroperitoneal lymph node dissection for low-stage nonseminomatous germ cell tumors

Objectives. To evaluate the incidence and sites of retroperitoneal recurrence after modified retroperitoneal lymph node dissection (RPLND) for low-stage nonseminomatous germ cell tumors (NSGCTs). Methods. A retrospective review of 88 patients who underwent RPLND for Stage I or II NSGCTs between 1971 and 1991 was performed to determine the incidence and site of any retroperitoneal recurrence. Results. Six retroperitoneal recurrences (four isolated and two in conjunction with failures at other sites) were found with a minimum follow-up of 5 years. All 6 patients had left-sided primary tumors, with three recurrences near the left renal hilum and two near the right renal hilum. All recurrences were at or outside the boundaries of the surgical dissection. Only one retroperitoneal recurrence may have been prevented by performing a bilateral dissection. Conclusions. Although uncommon, local recurrences can occur after RPLND. The right and especially the left renal hilum appear to be at higher risk of failure, possibly because of incomplete dissection in these areas. A more complete dissection in these areas may further decrease the local recurrence rate. Overall, the data presented and the studies reviewed suggest that modified RPLND reliably removes metastatic tumor with a low failure rate. If failures do occur, they are usually outside of the template and would not necessarily be prevented with a complete bilateral infrahilar dissection.

LAPAROSCOPIC RETROPERITONEAL LYMPHADENECTOMY FOR CANCER OF THE TESTIS

Laparoscopic retroperitoneal lymph node dissection (RPLND) is a technically advanced procedure that has been undertaken for the management of low-stage nonseminomatous germ cell testis tumor. Although it has been shown to be an effective staging technique, its role as a therapeutic operation is currently unknown. Laparoscopic RPLND requires longer operative times but offers the patient all the advantages of minimally invasive surgery, such as less postoperative pain and shorter hospitalization and convalescence. The role of laparoscopic RPLND for the evaluation of residual abdominal masses following chemotherapy is currently being examined.

Improved Accuracy of Computerized Tomography Based Clinical Staging in Low Stage Nonseminomatous Germ Cell Cancer Using Size Criteria of Retroperitoneal Lymph Nodes

Purpose We evaluated the significance of retroperitoneal lymph nodes detected by computerized tomography (CT) of low stage nonseminomatous germ cell tumor patients. Materials and Methods A blind retrospective review of 143 CTs of low stage nonseminomatous germ cell tumor revealed pathological stage A disease on 89 (62.2 percent) and pathological stage B disease on 54 (37.8 percent). A multivariate logistic regression model was used to evaluate the relationships between diameter of the retroperitoneal nodes detected in these CTs and pathological stage. Results Based on this model, as the diameter of the nodes increased within a 0 to 25 mm. range, the likelihood of pathological stage B disease increased in a continuous fashion. Using a 3 mm. threshold to define nonmetastatic nodes the sensitivity and negative predictive value of CT based staging was 90 percent. Conclusions This measurement scheme improves the accuracy of staging compared to conventional methods.

Improved Accuracy of Computerized Tomography Based Clinical Staging in Low Stage Nonseminomatous Germ Cell Cancer Using Size Criteria of Retroperitoneal Lymph Nodes

Improved Accuracy of Computerized Tomography Based Clinical Staging in Low Stage Nonseminomatous Germ Cell Cancer Using Size Criteria of Retroperitoneal Lymph Nodes