Retroperitoneal lymph node dissection for early stage nonseminomatous testicular germ cell tumors
- Graeme S Steele, MBBCh, FCS
Graeme S Steele, MBBCh, FCS
- Assistant Professor of Surgery
- Harvard Medical School
- Jerome P Richie, MD, FACS
Jerome P Richie, MD, FACS
- Section Editor — Cancer of the Urethra, Penis, and Ureter; Urologic Surgery; Prostate Cancer
- Elliott Carr Cutler Professor of Surgery
- Harvard Medical School
Germ cell tumors, which arise from germ cell elements within the seminiferous tubules, account for 90 to 95 percent of all testicular tumors (table 1). About half of these cases are seminomas, and the other half constitute nonseminomatous germ cell tumors (NSGCTs).
Historically, testicular cancer accounted for 11 percent of all cancer deaths in men between the ages of 25 and 34 with a five-year survival rate of 64 percent . With a better understanding of the natural history of testicular tumors, improved staging and surgical techniques, and the introduction of effective platinum-based combination chemotherapy, less than 500 deaths from testicular cancer occur in the United States per year, and five-year overall survival rates are consistently over 95 percent [2,3]. The high probability of cure for men with early-stage disease has shifted the focus toward reducing treatment-related effects on sexual and reproductive function and reducing the pulmonary, neural, and renal toxicities associated with chemotherapy. (See "Approach to the care of long-term testicular cancer survivors".)
Given the greater risk for nodal involvement for men with NSGCTs, these men are more likely to undergo a retroperitoneal lymph node dissection (RPLND) as part of their treatment. However, this procedure should only be performed by surgeons with appropriate technical expertise. The rationale and techniques for RPLND in men with early-stage (ie, stage I and IIA) NSGCTs will be reviewed here (table 2 and table 3). Other aspects of the management of men with testicular cancer, including the role of lymphadenectomy for men with more advanced germ cell tumors, are discussed separately. (See "Overview of the treatment of testicular germ cell tumors".)
OVERVIEW OF TREATMENT OPTIONS AFTER ORCHIECTOMY
Following orchiectomy, men with early-stage nonseminomatous germ cell tumors (NSGCTs) are candidates for active surveillance, a short course of chemotherapy, or retroperitoneal lymph node dissection (RPLND). Staging should include abdominal computed tomography (CT) scan, chest radiograph, and repeat tumor markers. If the tumor markers are rising or not decreasing by appropriate half-life, chemotherapy is the primary treatment. In general, the approach to management depends on the likelihood of relapse, relative importance of different toxicities for an individual patient, and the ability of the patient to adhere to active surveillance protocols. Given the overall excellent prognosis of men with early-stage NSGCTs, all of these options should be discussed with the patient. However, an RPLND should only be performed by experienced surgeons (ie, surgeons who perform at least 24 procedures annually). (See "Overview of the treatment of testicular germ cell tumors", section on 'Non-seminomatous germ cell tumor'.)
RATIONALE FOR RPLND
For men with early-stage nonseminomatous germ cell tumors (NSGCTs), retroperitoneal lymph node dissection (RPLND) is the only reliable method to identify nodal micrometastases, which may be an important factor in some patients. In addition, it is associated with low short and long-term morbidity . There are several advantages to the performance of RPLND rather than surveillance or adjuvant chemotherapy in men with stage I or II NSGCTs:
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- OVERVIEW OF TREATMENT OPTIONS AFTER ORCHIECTOMY
- RATIONALE FOR RPLND
- SURGICAL PRINCIPLES
- Metastatic pattern
- Anatomic considerations
- - Neuroanatomy
- - Lymphatics
- SURGICAL APPROACHES
- Open RPLND
- - RPLND-I
- - RPLND-II
- Laparoscopic RPLND
- Surgical template
- COMPLICATIONS FOLLOWING RPLND
- Sexual dysfunction
- SURVEILLANCE AFTER RPLND
- TREATMENT OF RELAPSE
- SUMMARY AND RECOMMENDATIONS