Retroperitoneal Lymph Node Dissection In Patients Research Articles

Prognostic Differences Between Surveillance and Active Treatment After Initial Orchiectomy in Patients With Stage I Mixed Germ Cell Tumors of the Testis: A Propensity Score Matching Analysis

IntroductionThe prognosis and optimal treatment approach for stage I mixed germ cell cancers of the testis are not well-established. This study aimed to assess contemporary treatment rates and their correlation with the cancer-specific mortality (CSM) and other-cause mortality (OCM) in patients with stage I testicular mixed germ cell tumors (TMGCT) who underwent orchiectomy, comparing surveillance with active treatment, including chemotherapy (CHT) and retroperitoneal lymph node dissection (RPLND). MethodsRetrospective analysis of clinical data from stage I TMGCT patients who underwent orchiectomy was conducted using the Surveillance, Epidemiology, and End Results database from 2004 to 2019. The annual percentage change (APC) in the use of surveillance, postoperative CHT, and RPLND was examined. Propensity score matching (PSM) and cumulative incidence, analyses were employed to compare differences in CSM and OCM between surveillance and active treatment, as well as between CHT and RPLND. Multivariate competing-risks regression models were utilized to investigate independent factors affecting CSM and OCM among stage I TMGCT patients. ResultsThe study included 5743 individuals with stage I TMGCT that underwent surveillance (61.6%), CHT(27.2%), or RPLND (11.2%). Among them, 82 deaths were attributed to TMGCT, and 82 deaths resulted from other causes. Surveillance rates increased over time (APC: 0.635%, P = 0.008), as did CHT rates (APC: 0.863%, P < 0.001), while RPLND rates declined (APC: −0.96%, P < 0.001). After PSM, multivariate competing-risks regression analysis showed that, active treatment, compared to surveillance, was not an independent factor for CSM and OCM. In contrast, when compared to CHT, RPLND was an independent factor associated with lower CSM (hazard ratio = 0.247, 95% confidence interval: 0.08-0.761; P = 0.015), but not OCM (hazard ratio = 0.946, 95% confidence interval: 0.377-2.37; P = 0.91). ConclusionsSurveillance and CHT rates have increased over time for patients with stage I TMGCT following initial orchiectomy, while RPLND utilization has decreased. There was no significant difference in CSM between surveillance and active treatment groups, but RPLND demonstrated significantly lower CSM than CHT in active treatment. Our findings suggest that the usage of RPLND in patients with stage I TMGCT should be reconsidered.

Contemporary analysis of complications after retroperitoneal lymph node dissection: Data from the National Surgical Quality Improvement Program 2006-2018.

416 Background: Retroperitoneal lymph node dissection (RPLND) offers therapeutic and diagnostic value for patients with testicular cancer. Specific indications for RPLND include management of patients with stage I-II nonseminomatous germ cell tumors (NSGCT), advanced NSGCTs with post-chemotherapy masses, and seminomas with early metastatic disease. While RPLND is an invasive and complex operation, prior research suggests complication rates are relatively low and may vary based on patient characteristics and disease-related factors. We examined the incidence of complications after RPLND and aimed to determine risk factors associated with these complications. Methods: The National Surgical Quality Improvement Program (NSQIP) database from 2006-2018 was queried for RPLND in patients with testis cancer who were identified by ICD 9 and 10 codes. All reported postoperative complications were examined and categorized by type and organ system. Univariable and multivariable logistic regressions were performed to determine risk factors associated with complications. Results: 368 RPLND procedures over the 13 year interval met inclusion criteria. The overall complication rate was 23.91% (n=88). The most common complication was bleeding requiring transfusion (n=59, 16.03%). Risk factors associated with any complication included older age (OR 1.041, p=0.003), longer operative time (OR 1.007, p&lt;0.001), and major concomitant procedure (OR 2.429, p=0.015). As shown in the table, risk factors associated with transfusion included older age (OR 1.040, p=0.019), longer operative time (OR 1.009, p&lt;0.001), and major concomitant procedure (OR 3.296, p=0.004). Higher pre-operative hematocrit was associated with decreased risk of transfusion (OR 0.883, p&lt;0.001). M+ (metastatic) disease and longer operative time were associated with an increased risk for wound, infectious, and respiratory complications. Conclusions: Based on our analysis, almost one in four patients undergoing RPLND experienced a complication. Bleeding requiring transfusion was the most common complication and was associated with patient age, preoperative hematocrit, operative time, and major concomitant procedure. Urologic surgeons may seek to optimize hematocrit prior to surgery, especially when major concomitant procedure may be necessary. [Table: see text]

Retroperitoneal lymph node staging in paratesticular rhabdomyosarcoma—are we meeting expectations?

BackgroundStaging retroperitoneal lymph node dissection (RPLND) for paratesticular rhabdomyosarcoma (RMS) is recommended for all patients aged ≥10 y. The purpose of this study was to evaluate adherence with surgical resection guidelines for RPLND in patients with paratesticular RMS as a measure for surgical quality. Materials and methodsAll patients with paratesticular RMS were identified in the Surveillance, Epidemiology, and End Results database from 1973 to 2012. Patients were divided into two eras to reflect before (1973-2002) and after (2003-2012) the release and dissemination of the 2001 surgical guidelines for staging ipsilateral RPLND in all patients aged ≥10 y with paratesticular RMS. Survival outcomes associated with lymph node dissection were calculated using the Kaplan–Meier method and Cox proportional hazards analysis. ResultsTwo hundred thirty-five patients with paratesticular RMS were identified and included in the study, among whom 111 were adolescents aged 10-20. RPLND did not significantly increase after 2003 among adolescents (45%-61%, P = 0.09). The benefit of RPLND on improved 5-y overall survival was evident among adolescents (92% versus 64%, P = 0.003). Adjusting for histology, age, stage at diagnosis, and race/ethnicity, RPLND was associated with improved overall survival among patients aged ≥10 y (hazard ratio 0.37, 95% confidence interval 0.17-0.83). ConclusionsDespite surgical guidelines recommending RPLND in pediatric patients aged ≥10 y, nearly one-third of adolescent patients did not undergo RPLND. These findings are disturbing considering the survival benefit associated with RPLND among adolescent patients and indicate an opportunity for improvement in surgical quality.

Retroperitoneal Lymph Node Staging in Paratesticular Rhabdomyosarcoma: Are We Meeting Expectations?

Abstract Background Staging retroperitoneal lymph node dissection (RPLND) for paratesticular rhabdomyosarcoma (RMS) is recommended for all patients aged ≥10 y. The purpose of this study was to evaluate adherence with surgical resection guidelines for RPLND in patients with paratesticular RMS as a measure for surgical quality. Materials and methods All patients with paratesticular RMS were identified in the Surveillance, Epidemiology, and End Results database from 1973 to 2012. Patients were divided into two eras to reflect before (1973-2002) and after (2003-2012) the release and dissemination of the 2001 surgical guidelines for staging ipsilateral RPLND in all patients aged ≥10 y with paratesticular RMS. Survival outcomes associated with lymph node dissection were calculated using the Kaplan–Meier method and Cox proportional hazards analysis. Results Two hundred thirty-five patients with paratesticular RMS were identified and included in the study, among whom 111 were adolescents aged 10-20. RPLND did not significantly increase after 2003 among adolescents (45%-61%, P = 0.09). The benefit of RPLND on improved 5-y overall survival was evident among adolescents (92% versus 64%, P = 0.003). Adjusting for histology, age, stage at diagnosis, and race/ethnicity, RPLND was associated with improved overall survival among patients aged ≥10 y (hazard ratio 0.37, 95% confidence interval 0.17-0.83). Conclusions Despite surgical guidelines recommending RPLND in pediatric patients aged ≥10 y, nearly one-third of adolescent patients did not undergo RPLND. These findings are disturbing considering the survival benefit associated with RPLND among adolescent patients and indicate an opportunity for improvement in surgical quality.

Primary Retroperitoneal Lymph Node Dissection in Low-stage Testicular Germ Cell Tumors: A Detailed Pathologic Study With Clinical Outcome Analysis With Special Emphasis on Patients Who Did Not Receive Adjuvant Therapy

To evaluate, in detail, the histopathologic features of metastatic testicular germ cell tumors to retroperitoneal lymph nodes treated with primary retroperitoneal lymph node dissection (RPLND) and correlate the findings with patients' outcomes. We studied 183 patients with documented pathologic stage II disease with or without elevated serum tumor markers, selected from 453 patients who underwent primary RPLND at our institution from 1989 to 2002. Tumor type(s), size and extent of disease, and amount of tumor necrosis were assessed and correlated with outcome. Embryonal carcinoma was the most common tumor type, present as the only component in 99 cases (54%) and the predominant tumor type (>50%) in 142 (78%). The number of positive lymph nodes ranged from 1 to 40 from a total of 2-80 lymph nodes examined (median, 28). Extranodal extension (ENE) was identified in 120 cases (66%). Among 73 patients followed up expectantly and with normal serum tumor markers, 19 experienced relapse, the probability of which was higher in patients with more positive nodes, larger metastases, and presence of ENE. However, none of these differences was statistically significant (all P >.2). The predominance of embryonal carcinoma and the presence of tumor necrosis were not significantly associated with outcome. In this cohort, most patients treated with primary RPLND and with positive lymph nodes also had ENE. We did not identify any variables to be significantly associated with relapse after RPLND in patients managed expectantly. Additional studies with more patients are needed to validate our findings.

Results of retroperitoneal lymph node dissection after chemotherapy in patients with pure seminoma in the orchidectomy specimen but elevated serum α‐fetoprotein

To determine the incidence of necrosis, teratoma, and active cancer in specimens at retroperitoneal lymph node dissection (RPLND) after chemotherapy in patients who presented with a pure seminoma primary tumour and an elevated serum alpha-fetoprotein (AFP) level at diagnosis who underwent surgery. A retrospective review of the Indiana University testis cancer database from 1980 to 2004 was performed to identify all patients with metastasic germ cell cancer, pure seminoma in the orchidectomy specimen, and an elevated AFP level. In all, 42 patients were identified; two with nonseminomatous germ cell cancer in the contralateral testicle were excluded. RPLND pathology in the 40 patients showed necrosis in 13 (32.5%), teratoma in 12 (30%), and cancer in 15 (37.5%). The histological subtype of the 15 cancer specimens at RPLND was pure seminoma in two, embryonal in three, yolk sac in seven, variant in one, and mixed elements in two (one with seminoma and yolk sac, and one with embryonal and variant). In all, 20 patients presented with a serum AFP level of <1000 microg/mL with nine (45%) having teratoma only in the retroperitoneum in contrast to 20 patients with an AFP level of >1000 microg/mL with three (15%) having teratoma only in the retroperitoneum (P = 0.04). The level of serum AFP did not predict for active cancer in the retroperitoneum (P = 0.5). RPLND in patients after chemotherapy who presented with pure seminoma in the orchidectomy specimen and an elevated AFP do not have a high probability of finding necrosis only in the RPLND specimen. In fact, the prevalence of persistent cancer is higher compared with the general group of patients that have RPLND after chemotherapy.

Postchemotherapy Laparoscopic Retroperitoneal Lymph Node Dissection in Nonseminomatous Germ-Cell Tumor

Postchemotherapy retroperitoneal lymph node dissection (RPLND) remains essential in the management of metastatic testicular carcinoma and represents a surgical challenge. We determined to assess the feasibility and complications of laparoscopic RPLND in patients who were treated with induction chemotherapy for testis cancer. We performed a retrospective analysis of data that was prospectively recorded from 26 patients who underwent laparoscopic RPLND postplatinum-based chemotherapy between 2000 and 2006. The surgical technique consisted of excision of the residual mass plus unilateral template dissection. A transperitoneal technique was used in 24 patients, and an extraperitoneal approach was used in 2 patients. Operative details, perioperative morbidity data, and histologic findings were assessed for the study. Primary pathologic evaluation of the testis tumor revealed pure embryonal carcinoma in 4 patients, teratocarcinoma in 1 patient, and mixed nonseminomatous germ-cell tumors in 21 patients. All patients had residual disease in the retroperitoneum on a preoperative CT scan, with a median size of 3.4 cm (range 2-6 cm). Procedures in three (11.5%) patients were converted to open surgery. Median operative time was 183 minutes (range 120-260 min). Median estimated blood loss was 400 mL (range 100-600 mL), and blood transfusion was necessary in one patient. Median hospital stay was 5 days (range 2-6 d). Median number of lymph nodes obtained on final histologic examination was 7 (range 4-13). Perioperative complications included eight lymphovascular and one intestinal. At a mean follow-up of 27 months (range 14-36 mos), no recurrences have been observed and no patient was lost to follow-up. Postchemotherapy laparoscopic RPLND is technically feasible. The most frequent complications and causes of conversion are lymphovascular.

Redefining the Refined Retroperitoneal Lymph Node Dissection in Testis Cancer: A SWOT Analysis of Nonrandomized Data

A SWOT analysis, generally used in a business sense, comprises of a strategic evaluation that includes strengths, weaknesses, opportunities and threats. Here, it is applied to a body of nonrandomized clinical and scientific data. The historical significance of using a multimodality treatment approach to metastatic cancer is best exemplified by nonseminomatous germ cell tumors of the testis (NSGCTT). The high, durable, and meaningful remission rates achieved in the cisplatin-based era in patients with both retroperitoneal disease and more distant metastases have improved continually with the evolution of combination programs. These include cisplatin with vinblastine and bleomycin; the evolution to etoposide replacement of vinblastine, with associated decrements in significant toxicities; elimination of bleomycin for certain risk categories; and lessening the duration of treatments. These advances have fuelled great optimism in developing strategic treatments that enhance cure and minimize toxicity. Accompanying the refinements of curative chemotherapy programs have been evolutionary developments in the surgical management of NSGCTT. Once the mainstay of treatment for NSGCTT that had metastasized to the retroperitoneum, the retroperitoneal lymph node dissection (RPLND) has also undergone extraordinary improvements in operative technique, patient selection, approach (open v laparoscopic), anatomic understanding of disease landing zones, and refinements to minimize ejaculatory disturbances (both retrograde ejaculation and failure to ejaculate) that have led to nerve-sparing approaches. These are all welcome advances to the teams of physicians who care for the young and otherwise healthy men with stage II NSGCTT. In this issue of the Journal of Clinical Oncology, Carver et al, representing the disciplines of Urologic Surgery and Medical Oncology from Memorial Sloan-Kettering Cancer Center (MSKCC; New York, NY), provide masterly analyses that redefine the already established refinements of RPLND. Such an analysis is especially appropriate to emanate from MSKCC, given that institution’s incredible contributions to the field that have been so important in providing advances embraced by physicians worldwide. The issue at hand relates to the appropriate extent of RPLND for patients with retroperitoneal NSGCTT after chemotherapy (postchemotherapy [PC] -RPLND). Given the correlation of greater ejaculatory morbidity associated with more extensive bilateral infrahilar RPLND for stage I NSGCTT and a more refined (but still incomplete) understanding of nodal landing sites for metastases, the concept of modified dissection templates emerged that limited surgical boundaries to the areas most likely to contain microscopic metastases or disease below the detection of radiographic tests, and thereby minimize postoperative ejaculatory dysfunction. Although no fewer than five modified dissection templates have been described, and are now often applied to the stage II patient, the authors point out that none have undergone rigorous follow-up when applied to stage II disease in the PC setting. In other words, is the performance of a template-modified RPLND correct in the setting of patients with stage II disease of varying tumor burdens? Such an analysis would provide the much-needed comfort that less (surgery) is better or equivalent (in oncologic efficacy). Unfortunately, the results of the current study cast serious doubt on this optimistic assumption. Short of performing a randomized study that compares both the safety and oncologic efficacy of a modified template to the more extensive bilateral infrahilar dissection in the PC setting, the authors analyzed (deduced and imputed) the nature and extent of retroperitoneal disease (teratoma or viable germ cell tumor GCT) PC. Their results include the nature of disease that would have persisted had a template RPLND been performed instead of a more extensive bilateral dissection. Given the poorer prognosis of late and uncontrolled retroperitoneal relapses, and the treacherous and wildly uncertain natural history of unresected teratoma, they argue further that the 7% to 32% of patients who would have had extratemplate disease would not have been well served by a more limited template RPLND. Can the informed reader arrive at the same conclusion? To answer that, let us evaluate the strengths, weaknesses, opportunities, and threats of the data interpretation presented by Carver et al. What are the strengths of the article? First, by any standard of NSGCTT patient experience, the database is huge. In a 14-year period at MSKCC, 532 stage II patients underwent a PC-RPLND, of whom 269 had evidence of either teratoma or viable GCT; of these, 7% to 32% (depending on the template selected) would have had evidence of extratemplate disease had a template RPLND been performed. JOURNAL OF CLINICAL ONCOLOGY E D I T O R I A L VOLUME 25 NUMBER 28 OCTOBER 1 2007

Does retroperitoneal lymph node dissection have a curative role for patients with sex cord-stromal testicular tumors?: Mosharafa AA, Foster RS, Bihrle R, Koch MO, Ulbright TM, Einhorn LH, Donohue JP, Department of Urology, Indiana University School of Medicine, Indianapolis, IN

Cancer 2003;98:753–7 Background Sex cord-stromal tumors account for < 5% of all adult testicular tumors, and 10% are malignant. Due to the limited reported experience, there is no agreement on the best management, especially in patients who have tumors with malignant pathologic features or who present with metastatic disease. The authors attempt to evaluate the role of retroperitoneal lymph node dissection (RPLND) in the management of patients with these malignant sex cord-stromal tumors. Methods Reviewing the Indiana University testis cancer registry revealed 17 patients who underwent RPLND for sex cord-stromal tumors. Pathology was reviewed for features suggestive of malignancy. The data examined included clinical and pathologic stage, surgical procedure, additional therapy received, and outcome. Results Pathology included Leydig tumors in six patients, Sertoli tumors in four patients, sex cord-stromal tumors in five patients, a granulosa cell tumor in one patient, and a poorly differentiated non-germ cell tumor in one patient. Nine patients had histologic features suggestive of malignancy. Clinical stage at surgery was Stage I in nine patients and Stage IIA-IIIA in eight patients. Patients underwent modified or bilateral RPLND. Nine patients had pathologic Stage I tumors, and the remaining eight patients and had pathologic Stage IIB-IIIA tumors. Follow-up ranged from 8 months to 11 years. Of the eight patients with Stage II-III disease, six patients eventually died of metastatic disease despite additional radiotherapy and/or chemotherapy. Conclusions Sex cord-stromal tumors have a potentially aggressive malignant behavior that is difficult to predict based on clinical and pathologic features. Although the therapeutic role of RPLND in patients with small-volume metastatic retroperitoneal tumors is unclear, RPLND remains an option to be performed immediately after orchiectomy, especially in patients who have tumors with malignant features and/or small-volume metastatic disease.

Does retroperitoneal lymph node dissection have a curative role for patients with sex cord-stromal testicular tumors?

Sex cord-stromal tumors account for < 5% of all adult testicular tumors, and 10% are malignant. Due to the limited reported experience, there is no agreement on the best management, especially in patients who have tumors with malignant pathologic features or who present with metastatic disease. The authors attempt to evaluate the role of retroperitoneal lymph node dissection (RPLND) in the management of patients with these malignant sex cord-stromal tumors. Reviewing the Indiana University testis cancer registry revealed 17 patients who underwent RPLND for sex cord-stromal tumors. Pathology was reviewed for features suggestive of malignancy. The data examined included clinical and pathologic stage, surgical procedure, additional therapy received, and outcome. Pathology included Leydig tumors in six patients, Sertoli tumors in four patients, sex cord-stromal tumors in five patients, a granulosa cell tumor in one patient, and a poorly differentiated non-germ cell tumor in one patient. Nine patients had histologic features suggestive of malignancy. Clinical stage at surgery was Stage I in nine patients and Stage IIA-IIIA in eight patients. Patients underwent modified or bilateral RPLND. Nine patients had pathologic Stage I tumors, and the remaining eight patients and had pathologic Stage IIB-IIIA tumors. Follow-up ranged from 8 months to 11 years. Of the eight patients with Stage II-III disease, six patients eventually died of metastatic disease despite additional radiotherapy and/or chemotherapy. Sex cord-stromal tumors have a potentially aggressive malignant behavior that is difficult to predict based on clinical and pathologic features. Although the therapeutic role of RPLND in patients with small-volume metastatic retroperitoneal tumors is unclear, RPLND remains an option to be performed immediately after orchiectomy, especially in patients who have tumors with malignant features and/or small-volume metastatic disease.

Adult primary pure teratoma of the testis. The Indiana experience

Pure testicular teratoma in adults is a relatively rare malignant tumor with the ability to invade and metastasize. Pure teratoma generally is believed to be less aggressive and less likely to progress, to present in lower stages, and to have better survival rates then other forms of germ cell tumor. Consequently, clinical stage A patients with pure testicular teratoma commonly have been considered to be managed best by surveillance. A computerized database search identified 41 patients presenting to Indian University with pure teratoma in the orchiectomy specimen. These patients were further subdivided into four groups based on clinical stage, as follows: Group I, 18 patients with clinical Stage A disease; Group II, 4 patients with clinical Stages A-B1 disease based on questionable computed tomography findings; Group III, 3 patients with clinical Stage B1 disease; Group IV, 16 patients with advanced stage (B3-C) disease. The experience with these patients was reviewed. The overall risk of lymph node metastasis in retroperitoneal lymph node dissection (RPLND) and the risk of relapse after RPLND for patients with low stage pure testicular teratoma (groups I-III) were 40 and 16%, respectively. In patients with clinical Stage A teratoma, the risk of retroperitoneal metastasis in RPLND was 16.7% and the relapse rate was 11.1%. In addition, nearly 37% of referred patients with pure teratoma presented with advanced disease. These data provide additional confirmation of the metastatic potential of pure testicular teratoma. The proper management of the adult clinical stage A patient with primary pure teratoma of the testis should not necessarily differ from the management of any other histologic type of nonseminomatous testicular tumor. Accordingly, histologic diagnosis of pure teratoma should not mandate surveillance. Instead, patients must be given adequate information regarding management options, as are all other patients presenting with clinical Stage A nonseminoma.