Comparison of surveillance and retroperitoneal lymph node dissection in Stage I nonseminomatous germ cell tumors

doi:10.1016/S0090-4295(02)01528-5

Urology

Volume 59, Issue 6, June 2002, Pages 923-929

https://doi.org/10.1016/S0090-4295(02)01528-5 Get rights and content

Abstract

Objectives. To compare retrospectively the treatment results of surveillance and primary retroperitoneal lymph node dissection (RPLND) of patients with clinical Stage I nonseminomatous germ cell tumors of the testis (NSGCT) in two institutions in The Netherlands.

Methods. From 1982 to 1994, 90 consecutive patients with clinical Stage I NSGCT were prospectively entered in a surveillance protocol in Amsterdam (group 1). In the same period, 101 patients with clinical Stage I NSGCT underwent primary RPLND in Nijmegen (group 2). Both patient populations were comparable for patient age, presence of vascular invasion, and embryonal cell components in the primary tumor. All patients in group 1 with relapse, except for 2, were treated with cisplatin-based chemotherapy. All patients in group 2 with vital tumor in the RPLND specimen were treated with two adjuvant courses of combined chemotherapy (cisplatin, etoposide, and bleomycin).

Results. In group 1, at a median follow-up of 7.7 years, 23 patients (26%) had relapse. The median time to relapse was 12 months. Relapses were located retroperitoneally (n = 18, 78%), in the lung (n = 3, 13%), scrotally (n = 1, 4%), and combined in the liver, lung, and pleura (n = 1, 4%). After treatment of relapses (chemotherapy in 21 and/or surgery in 11), only 1 patient died of disseminated disease. A disease-free survival rate of 98.5% was achieved at the median follow-up. The main toxicities consisted of short-lasting leukopenia, accompanied by infection (13%). Four patients reported cardiovascular and four neuropathy complaints. In group 2, the median follow-up was 6.9 years. In 31 patients (30.7%), vital tumor was found retroperitoneally; after two courses of combined chemotherapy, none of them had a relapse. Seven patients with pathologic Stage I disease (6.4%) had a pulmonary relapse within 1 year after surgery. No retroperitoneal relapses were found. After chemotherapy, 6 patients with relapse were salvaged, and 1 died of disseminated disease. The disease-specific survival rate in group 2 was 98% at the median follow-up. The most frequent surgical complications were lymphocele (n = 3), small bowel obstruction (n = 3), and abdominal pain (n = 3). The antegrade ejaculation rate was 94%.

Conclusions. Excellent treatment results in terms of disease-free survival can be achieved in Stage I NSGCT with both surveillance and primary RPLND. Patients with pathologic Stage II disease adjuvantly treated with chemotherapy did not have any relapse and consequently all survived. Most complications after both treatment strategies are reversible. The choice of treatment should be based on balanced information and not on dogmatic principles.

Section snippets

Material and methods

Retrospectively, we compared the treatment results of patients with clinical Stage I NSGCT who entered a surveillance protocol at the Departments of Urology and Oncology at the Netherlands Cancer Institute Amsterdam/Antoni van Leeuwenhoek Hospital, Amsterdam (group 1) with those who underwent RPLND at the Department of Urology at the University Medical Center Nijmegen (group 2). Staging was done according to the criteria of the Royal Marsden Hospital.9 Clinical Stage I NSGCT was defined as no

Results

In group 1, disease relapse was recorded in 23 (26%) of the 90 patients; 16 (70%) were detected in the first year, 4 in the second year, and the remaining 3 at 34 months (n = 2) and 44 months (n = 1). Relapses were located retroperitoneally (n = 18, 78%), in the lung (n = 3, 13%), scrotally (n = 1, 4%), and combined in the liver, lung, and pleura (n = 1, 4%). Evidence of relapse was detected in 15 (65.2%) of 23 cases by both tumor markers and imaging studies. The median time to relapse was 12

Comment

This study compared routine management in two institutions in The Netherlands for clinical Stage I NSGCT. In one institution, this comprises surveillance and in the other RPLND. The two groups of patients were well balanced for clinical and pathologic parameters, enabling a comparison of the treatment results.

Despite advances in diagnostic radiology (CT11 and positron emission tomography12), the controversy concerning the treatment of Stage I NSGCT is mainly caused by the inaccuracy of clinical

Conclusions

Surveillance and RPLND with adjuvant chemotherapy for Stage I NSGCT show comparable cancer-specific survival figures. The debate on the most appropriate management is still unsettled and awaits refinement of prognostic factors and/or more reliable imaging techniques enabling detection of microscopic metastasis. Patients should be offered a choice, based on balanced information on treatment-related morbidity. Today, the choice of treatment will depend on the local expertise and treatment and

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Citation Excerpt :
Some have argued that the high rate of adjuvant chemotherapy administration reflects an overall concern regarding the therapeutic efficacy of L-RPLND. However, reviewing previous reports shows that the chemotherapy rate is similar for node-positive patients undergoing both laparoscopic and open node dissections (29% and 31%, respectively) [22–31]. Another criticism of L-RPLND is related with nodal yield.
Laparoscopic retroperitoneal lymph node dissection (L-RPLND) was introduced over 20 years ago as a less invasive alternative to open node dissection. In this review we summarise the indications, surgical technique and outcomes of L-RPLND in the treatment of testicular cancer.
We searched MEDLINE using the terms ‘laparoscopy’, ‘laparoscopic’, ‘retroperitoneal lymph node dissection’, ‘RPLND’ and ‘testicular neoplasms’. Articles were selected on the basis of their relevance, study design and content, with an emphasis on more recent data.
We found 14 pertinent studies, which included >1300 patients who received either L-RPLND (515) or open RPLND (788). L-RPLND was associated with longer mean operative times (204 vs. 186 min), but shorter hospital stays (3.3 vs. 6.6 days) and lower complication rates (15.6% vs. 33%). Oncological outcomes were similar between L-RPLND and open RPLND, with local relapse rates of 1.3% and 1.4%, incidence of distal progression of 3.3% and 6.1%, biochemical failure in 0.9% and 1.1% and cure rates of 100% and 99.6%, respectively.
There are no randomised controlled studies comparing L-RPLND with open RPLND. A review of case and comparative series showed similar perioperative and oncological outcomes. Patients undergoing L-RPLND on average have shorter hospital stays, a quicker return to normal activity and improved cosmesis.
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Non-seminomatous germ cell testicular cancer is a curable neoplasia. All available treatment modalities produce excellent results, with a long-term survival of almost 100%. Consequently, therapy-induced toxicity is an important concern in the management of these patients. An individually tailored approach that takes into account the prognostic factor profile, as well as the patients’ preferences and their ability to comply with treatment, is the key for the successful management of stage I testicular cancer.
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The high rates of antegrade ejaculation yielding 97–100% in contemporary L-RPLND series reflect the relevance of the Colleselli study [57]. It may be difficult to understand why the use of carbon dioxide insufflation and a laparoscopic en bloc dissection technique may be superior compared with previous open studies using a modified template (0–2% vs 7–14%) or even a nerve-sparing dissection with 2–6% loss of ejaculation [16,17,50,53,56]. This difference could be related to a less-extended dissection and/or the learning curve of the nerve-sparing technique.
Laparoscopic retroperitoneal lymph node dissection (L-RPLND) is not recommended as standard tool in European Association of Urology (EAU) guidelines.
To update the role of L-RPLND in patients with clinical stage I nonseminomatous germ cell tumour (NSGCT) compared to open retroperitoneal lymph node dissection (O-RPLND).
A systematic literature search from 1992 to 2008 was performed in Medline, EMBASE, and Cochrane. The largest series from each group was considered. Comparative analysis was based on raw data of series published in 2000 and later.
Results of >800 patients treated by L-RPLND reported in 34 articles were analyzed. Lymph node dissection (LND) was based on modified templates, removing an average of 16 (5–36) lymph nodes. At experienced centres, complication rates were 15.6% (9.4–25.7), including 2% (0–5) retrograde ejaculation and 1.7% (0–6) reintervention. Operating room times are longer compared to O-RPLND (204 vs 186 min). Five publications with a follow-up of 63 (36–89) mo include 557 patients. One hundred twenty-six of 140 (90%) patients with positive nodes (25%, range: 17–38) received adjuvant chemotherapy, resulting in a local relapse rate of 1.4% (0.7–2.3) with no in-field recurrence; rate of distant relapses was 3.3% (1.8–4.6), including one port-site metastasis; and rate of biochemical failure was 0.9% (0.7–2.3). Two of 14 patients with positive nodes (pN1) who did not receive adjuvant chemotherapy relapsed, both 8 mo after surgery, and were salvaged by chemotherapy.
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L-RPLND offers similar staging accuracy and long-term outcome to O-RPLND. In a late series of experienced L-RPLND centres, there was a trend towards fewer complications. L-RPLND represents a valuable tool for experienced laparoscopic surgeons. Further studies must focus on the curative potential of the procedure in pathologic stage IIA.

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Adult urology: CME articleComparison of surveillance and retroperitoneal lymph node dissection in Stage I nonseminomatous germ cell tumors

Abstract

Section snippets

Material and methods

Results

Comment

Conclusions

Lancet

J Urol

Urology

J Urol

Urology

J Urol

J Urol

Medical Research Council prospective study of surveillance for stage I testicular teratoma

J Clin Oncol

Primary retroperitoneal lymph node dissection in clinical stage A non-seminomatous germ cell testis cancerreview of the Indiana University experience 1965–1989

Br J Urol

Prognostic risk factors that identify patients with clinical stage I nonseminomatous germ cell tumors at low risk and high risk for metastasis

Cancer

Adult urology: CME article
Comparison of surveillance and retroperitoneal lymph node dissection in Stage I nonseminomatous germ cell tumors