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 400 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:
- Einhorn LH. Treatment of testicular cancer: a new and improved model. J Clin Oncol 1990; 8:1777.
- Ries LA, Eisner MP, Kosary CL, et al. SEER Cancer Statistics Review, 1975-2001, National Cancer Institute, Bethesda, MD, 2004 http://seer.cancer.gov/csr/1975_2007/index.html (Accessed on April 11, 2011).
- Siegel RL, Miller KD, Jemal A. Cancer statistics, 2016. CA Cancer J Clin 2016; 66:7.
- Heidenreich A, Albers P, Hartmann M, et al. Complications of primary nerve sparing retroperitoneal lymph node dissection for clinical stage I nonseminomatous germ cell tumors of the testis: experience of the German Testicular Cancer Study Group. J Urol 2003; 169:1710.
- NCCN Clinical Practice Guidelines in Oncology: Testicular Cancer (version 1.2013). http://www.nccn.org/professionals/physician_gls/pdf/testicular.pdf (Accessed on May 29, 2013).
- Albers P, Siener R, Kliesch S, et al. Risk factors for relapse in clinical stage I nonseminomatous testicular germ cell tumors: results of the German Testicular Cancer Study Group Trial. J Clin Oncol 2003; 21:1505.
- Herr HW, Bar-Chama N, O'Sullivan M, Sogani PC. Paternity in men with stage I testis tumors on surveillance. J Clin Oncol 1998; 16:733.
- Large MC, Sheinfeld J, Eggener SE. Retroperitoneal lymph node dissection: reassessment of modified templates. BJU Int 2009; 104:1369.
- Donohue JP, Zachary JM, Maynard BR. Distribution of nodal metastases in nonseminomatous testis cancer. J Urol 1982; 128:315.
- Brydøy M, Fosså SD, Klepp O, et al. Paternity following treatment for testicular cancer. J Natl Cancer Inst 2005; 97:1580.
- Carver BS, Sheinfeld J. The current status of laparoscopic retroperitoneal lymph node dissection for non-seminomatous germ-cell tumors. Nat Clin Pract Urol 2005; 2:330.
- Janetschek G, Hobisch A, Peschel R, et al. Laparoscopic retroperitoneal lymph node dissection for clinical stage I nonseminomatous testicular carcinoma: long-term outcome. J Urol 2000; 163:1793.
- Bhayani SB, Ong A, Oh WK, et al. Laparoscopic retroperitoneal lymph node dissection for clinical stage I nonseminomatous germ cell testicular cancer: a long-term update. Urology 2003; 62:324.
- Rassweiler JJ, Frede T, Lenz E, et al. Long-term experience with laparoscopic retroperitoneal lymph node dissection in the management of low-stage testis cancer. Eur Urol 2000; 37:251.
- Cresswell J, Scheitlin W, Gozen A, et al. Laparoscopic retroperitoneal lymph node dissection combined with adjuvant chemotherapy for pathological stage II disease in nonseminomatous germ cell tumours: a 15-year experience. BJU Int 2008; 102:844.
- Beck SD, Bey AL, Bihrle R, Foster RS. Ejaculatory status and fertility rates after primary retroperitoneal lymph node dissection. J Urol 2010; 184:2078.
- Steiner H, Zangerl F, Stöhr B, et al. Results of bilateral nerve sparing laparoscopic retroperitoneal lymph node dissection for testicular cancer. J Urol 2008; 180:1348.
- Matos E, Skrbinc B, Zakotnik B. Fertility in patients treated for testicular cancer. J Cancer Surviv 2010; 4:274.
- Nicolai N, Miceli R, Artusi R, et al. A simple model for predicting nodal metastasis in patients with clinical stage I nonseminomatous germ cell testicular tumors undergoing retroperitoneal lymph node dissection only. J Urol 2004; 171:172.
- 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